Columbia  toiber.«itp  gj^j  \ . 
in  tfjeCitp  of  i^ctogorfe 

College  of  ^fjpsicians  anb  ^urgeong 


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OPERATIVE  SURGERY 


OPERATIVE   SURGERY 


BY 
J.  SHELTOX  HORSLEY,  M.D.,  F.A.C.S., 

Attending  Surgeon,  St.  Elizabeth's  Hospital,  Eichmond,  Va. 


WITH  613  ORIGINAL  ILLUSTRATIONS 

Illustrated  by  Miss  Helen  Lorraine 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1921 


Copyright,  1921,  By  C.  V.  Mosby  Cojipaxy 
(All  rights  reserved) 


Printed  in  U.S.A. 


I^  3)iX 


Press  of 

C.  V.  Mosby  Company 
St.  Louis 


THIS  VOLUME  IS  AFFECTIONATELY 

DEDICATED  TO 

MY  EIGHT  CHILDREN 


'"yiuuL. 


PREFACE 

In  this  book  particular  stress  has  been  Laid  upon  the  preservation  of  phys- 
iologic function  and  the  interpretation  of  the  biologic  processes  that  follow 
surgical  operations. 

Naturally,  a  knowledge  of  anatomy  is  essential  for  operative  surgery, 
but  in  many  regions  of  the  body  an  etfort  to  conserve  or  to  restore  as  far  as 
possible  the  physiologic  function  of  the  tissues  involved  in  the  operation  has 
often  been  neglected.  Merely  following  anatomical  landmarks  and  making 
a  beautiful  dissection  with  accurately  placed  ligatures  and  sutures  should  not 
be  the  sole  aim  of  the  surgeon.  These  things,  of  course,  should  be  included 
in  the  surgeon's  ideals,  but  it  is  even  more  important  that  the  operation  re- 
sults in  the  extirpation  or  correction  of  the  pathology,  and  in  the  restoration 
of  the  physiology  of  the  tissues  or  organs.  One  of  the  chief  aims  of  this 
book  is  to  emphasize  those  physiologic  and  biologic  principles  which,  to  some 
extent,  obtain  in  every  surgical  operation. 

The  biologic  processes  that  follow  the  application  of  surgical  drainage, 
for  instance,  have  been  too  frequently  not  considered  at  all  and  surgical  drain- 
age has  been  regarded  as  solely  or  chiefly  mechanical.  The  treatment  of  frac- 
tures by  metal  plates  or  screws  produces  excellent  immediate  mechanical  re- 
sults, but  a  little  study  of  the  biologic  processes  following  the  use  of  metal 
plates  should  convince  the  surgeon  that  this  is  not  a  satisfactory  operation. 
Physiologic  principles,  if  logically  followed,  in  operations  for  ulcer  of  the 
stomach  and  for  resection  of  the  intestine,  appear  to  lead  to  certain  definite 
technics,  even  though  others  may  be  anatomically  and  mechanically  unob- 
jectionable. The  development  of  collateral  circulation  around  an  aneurism  by 
partial  or  intermittent  occlusion  of  the  artery,  as  has  been  practiced  by  Hals- 
ted  and  by  Matas,  is  often  a  much  safer  procedure  than  the  immediate  and 
permanent  occlusion  of  the  vessel.  Developing  a  blood  supply  in  the  pedicle 
of  a  flap  by  the  gradual  dissection  of  the  flap  in  dit^erent  stages,  insures  against 
gangrene  and  makes  possible  better  plastic  results  because  it  brings  more  nu- 
trition to  the  reconstructed  tissues.  There  are  many  other  examples  that  might 
be  cited. 

No  attempt  has  been  made  to  include  in  this  volume  all  surgical  opera- 
tions. Such  an  enclycopedia  of  operations  is  found  in  many  excellent  text 
books  and  systems  of  surgery.  Every  operation  that  I  have  described  is 
either  one  that  I  have  done  or  else  an  operation  that  appears  to  me  to  be  the 
one  best  suited  for  the  disease.  Frequently,  conditions  are  such  that  different 
operations  may  be  indicated  for  what  appears  to  be  the  same  affection.  In 
order  to  meet  this  situation,  I  have  often  described  several  operations,  each 
one  of  which  I  believe,  under  certain  conditions,  would  be  appropriate.  In  this 
Avay  the  book  is  to  a  considerable  extent  a  record  of  my  personal  experience. 

9 


10  PREFACE 

All  of  the  drawings  are  by  ]\Iiss  Helen  Lorraine,  exee])t  the  illustrations 
of  Dr.  J.  AV.  Long's  enterostomy,  Avhich  were  drawn  l)y  William  F.  Didusch. 

It  is  a  pleasure  to  acknowledge  my  obligation  to  Mrs.  A.  C.  Norris,  my 
former  secretary,  -who,  in  spite  of  her  domestic  duties,  consented  to  help  in  the 
preparation  of  the  manuscript  for  this  book.  She  has  greatly  lightened  the 
labor  of  its  preparation. 

jNIy  thanks  are  due  Dr.  W.  T.  Graham  for  many  helpful  suggestions  about 
the  sections  dealing  with  orthopedic  surgical  operations. 

J.  Shelton  Horsley. 

Eichmoiul,  Ya. 


CONTENTS 


PAGE 
CHAPTER  I 
Gexekal  Considerations 29 

CHAPTEE  II 

Surgical  Drainage 35 

Classification  of  Surgical  Drainage,  36;  Drainage  Material,  41;  Encapsulated  For- 
eign Bodies  in  the  Peritoneum,  42;  Criticisms,  42. 

CHAPTER  III 
Technic,  Sutures,  and  Instruments 44 

CHAPTER  IV 

Complications  of  Operations;    Infection,  Shock,  and   Hemorrhage 51 

CHAPTER  V 

Transfusion    of   Blood 59 

Technic  for  Direct  Transfusion  of  Blood,  62. 

CHAPTER  VI 

Suturing  Blood  Vessels       69 

Lateral  and  Incomplete  Transverse  AVounds  of  Blood  A^essels,  90. 

CHAPTER  VII 
Reversal  of  the  Circulation 92 

CHAPTER  VIII 

Ligation  of  Blood  Vessels 97 

Ligation  of  the  Innominate  Artery,  100;  Ligation  of  the  Common  Carotid  Artery, 
101;  Ligation  of  the  External  Carotid  Artery,  102;  Ligation  of  the  Superior  Thy- 
roid, 104;  Ligation  of  the  Internal  Carotid  Artery,  105;  Ligation  of  the  Subclavian 
Artery,  105;  Ligation  of  the  Vertebral  Artery,  107;  Ligation  of  the  Inferior  Thy- 
roid Artery,  107;  Ligation  of  the  Axillary  Artery,  108;  Ligation  of  the  Brachial 
Artery,  109;  Ligation  of  the  Radial  and  Ulnar  Arteries,  109;  Ligation  of  the  Ab- 
dominal Aorta,  110;  Ligation  of  the  Common  Iliac  Artery,  110;  Ligation  of  the 
Internal  Iliac  Artery,  111;  Ligation  of  the  External  Iliac  Artery,  112;  Ligation  of 
the  Femoral  Artery,  113;  Ligation  of  the  Popliteal  Artery,  115;  Ligation  of  the 
Anterior  Tibial  Artery,  116;  Ligation  of  the  Dorsalis  Pedis,  116;  Ligation  of  the 
Posterior  Tibial  Artery,  117. 

CHAPTER  IX 

Aneurisms 118 

Operation  for  Aneurisms  of  Special  Arteries,  126. 

11 


12 


CONTEXTS 


PAGE 
CHAPTER  X 
Arteriovenous  Aneurisms 133 

CHAPTER  XI 
Operations  for  Repair  of  Nerves 141 

CHAPTER  XII 
Operations  on  Bones 157 

CHAPTER  XIII 
Plastic  Surgery 172 

CHAPTER  XIV 

Operations  on  the  Face  and  Mouth 187 

Cleft  Palate,  195;  The  Lips,  198;  The  Eyelids,  210;  Ears,  222;  The  External  Nose, 
224;  The  Forehead,  236;  Tumors  of  the  Face,  238;  The  Parotid  Gland,  240;  The 
Tongue,  245;  Upper  Jaw,  252;  Lower  Jaw,  254;  Peripheral  Operations  on  the 
Fifth  Nerve,  258. 

CHAPTER  XV 

Operations  on  the  Scalp,  Skull  and  Brain 261 

Operations  for  Epilepsy,  268;  Operations  for  Hydrocephalus,  272;  Operations  on 
the  Hypophysis,  275;  Congenital  Hernias  of  the  Brain  or  Its  Membranes,  276;  De- 
compression Operations,  279;   Operations  on  the  Gasserian  Ganglion,  283. 

CHAPTER  XVI 

Operations  on  the  Spine 288 

Laminectomy,  290;   Spina  Bifida,  296. 

CHAPTER  XVII 

Operations  on  the  Neck 303 

Cystic  Hygroma  and  Congenital  Cysts,  304;  Cervical  Ribs,  308;  Torticollis,  308; 
Tubercular  Glands  of  the  Neck,  309;  Malignant  Growths  of  the  Neck,  310;  The 
Larynx  and  Trachea,  316;  Pharynx  and  Esophagus,  321;  The  Carotid  Gland,  323; 
Diffuse  Lipoma  of  the  Neck,  324;  The  Cervical  Sympathetic,  325;  The  Thyroid 
Gland,  326, 

CHAPTER  XVIII 

Operations  on  the  Upper  Extremities 331 

Amputations,  331;  Excisions,  350;  Arthrodesis  of  the  Elbow,  355;  Infection  of  the 
Hand,  356;  Deformities,  358;  Subacromial  Bursitis,  369. 

CHAPTER  XIX 

Operations  on  the  Lower  Extremity 370 

Am.putations,  370;  Tendons  and  Muscles,  385;  Deformities  of  the  Ankle  Joint,  401; 
Ingrowing  Nail,  406;  The  Joints,  407;  Osteotomy,  417;  Arthroplasty,  420;  Osteo- 
myelitis, 421;  Elephantiasis,  427;  Varicose  Veins,  428;  The  Sciatic  Nerve  and 
Branches,  430. 


CONTENTS  13 

PAGE 
CHAPTER  XX 

Operations  on  the  Thorax  Except  the  MammaPv-y  Gland 432 

The  Ribs,  4;?2 ;  Empyema,  437;  The  Lung,  443;  The  Pericar.liuni  and  Heart,  452; 
The  Heart,  453;  Paralysis  of  Muscles  of  tlic  Tlioiax,  4.1S;  Tlie  Scapula  and  Clav- 
icle, 460. 

CHAPTER  XXI 
Operations  on  the  MamjiapvY  Gland 462 

CHAPTER  XXTI 

Operations   for   Hernia 477 

Inguinal  Hernia,  479;  Femoral  Hernia,  493;  Umbilical  Hernia,  499;  Incisional  or 
Ventral  Hernia,  502;  Epigastric  Hernia,  504;  Diaphragmatic  Hernia,  505. 

CHAPTER  XXIII 
Abdominal   Incisions 508 

Closure  of  Abdominal  Incisions,  514. 

CHAPTER  XXIV 
Operations  on  the  Liver,  Gall  Bladder,  Bile  Tracts,  Pancreas,  and  Spleen     .     .     520 

CHAPTER  XXV 
Operations  on  the  Stomach 543 

CHAPTER  XXVI 

Operation   on  the  Intestines 585 

The  Technic  of  Suturing  Wounds  of  the  Stomach  and  Intestines,  585;  Enterostomy, 
589;  Intestinal  Resection,  603. 

CHAPTER  XXA'II 
Operations  on  the  Appendix,  Pericolonic  Bands,  the  Loavef^  Sigmoid,  the  Rectum, 

AND  the  Anus 623 

Appendicitis,  623 ;  Pericolonic  Bands,  637 ;  The  Terminal  Sigmoid,  the  Rectum,  and 
Anus,  639;  Hemorrhoids,  654;  Pruritus  Ani,  659;  Sacral  and  Coccygeal  Dermoids, 
661. 

CHAPTER  XXVIII 

Operations  on  the  Kidney,  Ureter  and  Bladder 663 

The  Kidneys,  663;   The  Ureter,  675;   The  Bladder,  684. 

CHAPTER  XXIX 

Operations  on  the  Prostate  Gland,  the  Testicles  and  the  Penis 690 

The  Seminal  Vesicles^  the  A'as  Deferens,  and  Testicles,  700. 


ILLUSTRATIONS 


FIG.  P^^«^ 

1.  Eoef  or  flat  knot •^'' 

2.  "Granny"    knot ■*" 

3.  Grant's  method  of  tying  knot  with  forceps 49 

4.  Second  stage  of  Grant's  method  of  tying  knot  with  forceps 49 

5.  Tliird  stage   of  Grant's  method  of  tying  knot  with  forceps 49 

6.  Fourth  stage  of  Grant's  method  of  tying  knot  with  forceps 49 

7.  Fifth  stage  of  Grant's  method  of  tying  knot  with   forceps 50 

8.  Sixth   stage   of  Grant's  method  of  tying  knot  with   forceps 50 

9.  Seventh   stage   of   Grant's  method   of  tying  knot   with   forceps 50 

10.  The  knot   completed 50 

11.  Incision   of  abdominal   wall 53 

12.  The  author's  method  of  transfusion  of  blood  with  the  arterial  suture  staff     ....  60 

13.  Crile's  cannula  for  transfusion 61 

14.  The  vein  is  drawn  through  the  cannula  with  a  line  suture 61 

15.  The  vein  is  cuffed  back  over  the  cannula 61 

16.  The  vein  has  been  cuffed  back  and  tied,  and  the  artery  is  about  to  be  drawn  over  the 

cuff     ... 61 

17.  The  last   stage   of  application   of  Crile's  cannula 61 

18.  Bernheim's  cannula  for  transfusion 64 

19.  Kimpton  and  Brown's  cannula  for  transfusion 65 

20.  Kimpton  and  Baown's  cannula,  in  horizontal  xjosition,  showing  the  trap  which  prevents 

the  entrance  of  air  iu  the  cannula 65 

21.  Incision  in  skin  to  expose  vein 67 

22.  Incision  in  vein  for  intravenous  infusion 67 

23.  First  stage   of  Carrel's  method  of  suturing  blood  vessels 71 

24.  Second  stage  of  Carrel's  method  of  suturing  blood  vessels 72 

25.  Third  stage  of  Carrel's  method  of  suturing  blood  vessels 73 

26.  Operation  of  Carrel  completed 73 

27.  The  lumen  of  a  blood  vessel  immediately  after  suturing  by  method  of  Carrel     ...  75 

28.  The  lumen  of  a  blood  vessel  several  weeks  after  suturing  by  method  of  Carrel     ...  75 

29.  The  lumen  of  a  blood  vessel  immediately  after  suturing  by  author  's  method     ...  75 

30.  Special  instruments  used  in  the  author 's  method  of  end-to-end  suturing  of  blood  vessels  76 

31.  The  artery  is  exposed,  blood  stripped  from  it,  and  serrefine  clamps  are  placed     ...  77 

32.  The  artery  has  been  severed  by  sharp  scissors  and  the  adventitia  is  pulled  down  and 

cut  away  with  scissors 77 

33.  The  thumb  and  finger  of  the  left  hand  grasp  the  end  of  the  artery  after  the  adven- 

titia has  been  cut  away  and  olive  oil  is  dropped  on  the  artery 78 

34.  The  first  suture  has  been  placed  and  is  wrapped  around  the  lowest  button  on  the  long 

shaft  and  cut   short , 78 

35.  Inserting   a    second   suture 79 

36.  Inserting  a  third  suture 80 

37.  The  third  suture  is  wrapped  around  a  button  on  the  short  shaft 81 

38.  The   three  guy  sutures  have  been  inserted 82 

39.  Suturing  in  the  first  third  is  begun S3 

40.  Suturing  of  the  second  third 84 

15 


Jl  6  ILLUSTRATIONS 

^^^-  PAGE 

41.  Suturing  the  last    third gg 

42.  The   suturing  has   been   completed 86 

43.  External  appearance  of  the  femoral  artery  of  a  dog  after  eiul-to-cnd  suturing     .     ,  87 

44.  Internal  appearance  of  the  carotid  artery  of  a  dog  after  end-to-end  suturing     ...  87 

45.  Internal  appearance  of  arteriovenous  union  thirty-nine  days  after  operation     ...  88 

46.  Internal  appearance  of  transplantation  of  a  segment  of  vein  sixty -three  days  after 

operation gg 

47.  Photograph  of  a  specimen  in  ^vllic•ll  a  rubber  tube  was  sutured  into  a  defect  in  tlie 

abdominal  aorta   of  a   dog 89 

48.  A  roentgenogram  of  reversal  of  the  circulation  in  a  dog's  hiud  extremity     ....  9.3 

49.  A  roentgenogram  of  cinnabar  mass  which  was  injected  into  the  reversed  circulation     .  9.3 

50.  A  roentgenogram  of  cinnabar  mass  injected  into  reversed  circulation 93 

51.  A  roentgenogram  of  the  same  dog  shown  in  Fig.  50,  but  with  the  systemic  arterial 

system  injected  with  a  bismuth  mass  through  the  carotid 93 

52.  Binuie  's  method  of  passing  a  stout  catgut  ligature 98 

53.  Ligation  of  the  femoral  artery,  showing  method  of  applying  two  ligatures     ....  99 

54.  Ligation  of  the  common  carotid,  external  carotid,  and  the  first  four  branches  of  the 

external  carotid 103 

55.  Ligation  of  the  superior  thyroid   artery 104 

56.  Ligation   of  the   subclavian  artery 106 

57.  Ligation  of  the  internal  iliae   artery 112 

58.  Ligation  of  the  right  femoral  artery  just  below  Poupart  's  ligament 114 

59.  The  operation  of  Antyllus  for  aneurism 121 

60.  The  operation   of  Anel  for   aneurism 121 

61.  The   operation   of   John   Hunter 121 

62.  The  operation  of  Brasdor 121 

63.  The  operation  of  Wardrop 121 

64.  The  operation  of  Pasquiu 121 

do.  The  operation  of  Purmann 121 

66.  Obliterative  endo-aneuiismorrhaphy   of  Matas 123 

67.  Eestorative   endo-aneurisniorrhaphy  of   Matas 124 

68.  Eeconstructive   endo-aneurismorrhaphy   of  Matas 124 

69.  Traumatic  aneurism  of  the  temporal  artery 131 

70.  The  excised  sae  of  the  traumatic  aneurism  shown  in  Fig.  69 131 

71.  The  second  case  of  traumatic  aneurism  of  the  temporal  artery 132 

72.  Drawing  of  the  excised  sac  shown  m  Fig.   71 132 

73.  The  author's  forceps  for  lateral  blood  vessel  suturing 136 

74.  Method  of  applying  the  forceps 136 

75.  The  vein  and  artery  have  been  clamped  with  the  forceps 136 

76.  The  communication  betAveen  the  artery  and  vein  has  been  severed 136 

77.  Arteriovenous  aneurism  of  the  left  femoral,  near  Poupart 's  ligament 137 

78.  Ligatures  applied  to  femoral  artery  and  vein 138 

79.  Quintuple  ligature  in  arterio\enous  aneurism 139 

80.  Appearance  of  nerves  after  suturing 144 

81.  Dissection  of  binding  scar  tissue  from  a  nerve 145 

82.  Pedicle  flap  applied  around  the  old  site  of  scar  contraction 145 

S3.  Excision  of  neuromas  from  a  divided  nerve 146 

84.  Application  of  a  tube  of  fat  and  fascia  between  ends  of  a  nerve 146 

85.  Elsberg's  method  of  cutting  sections  of  a  small  nerve  for  cable  transplantation     .     .  147 

86.  Cable  shown  in  Fig.  85  is  being  sutured  into  the  defect 147 

87.  Appearance  of  nerve  after  cable  graft  has  been  completed 148 

88.  Eud-to-side  suturing  of  a  nerve 149 


ILLUSTRATIONS  17 

FIG.  PAGE 

89.  The  iiu'tlHiil  of  bridging  a  clffcet  m  a  nerve  by   flaps 150 

90.  Suturiiio-  tlie  hypoglossal  nerve  to  tiie  facial  nerve 152 

91.  Diagram  ot  tlie  brachial  plexus.     (After  Gray.) 154 

92.  Injury  of  tlie  upper  trunk  of  the  bracliial  plexus 154 

93.  Excision  of  the  injured  j)ortion  of  the  brachial  plexus 155 

94.  Placing  an  intramedullary  bone  graft 163 

95.  Hoglund's  method  of  placing  an  intramedullary  graft 163 

96.  Albee  's  method  of   inlay  bone   grafting 164 

97.  Inlay  method  of  bone  grafting  of  bones  of  the  forearm 165 

98.  A  method  of  extension  that  can  be  used  after  operation  on  tlie  bones  of  the   arm 

or  forearm 167 

09.  Diagram  showing  the  action  of  bone  graft  in  Pott's  disease  of  the  spijie     ....  168 

100.  Albee 's  method  of  bone  graft  in  Pott 's  disease  of  the  spine 169 

101.  The  size  and  shape  of  the  graft  as  determined  by  a  malleable  probe 169 

102.  The  bone  graft  has  been  cut^  molded,  and  placed  in  position 170 

103.  Closure  of  a  triangular  defect  by  the  method  of  Jasche 176 

104.  Closure  of  a  triangular  defect  by  the  method  of  Szymonowski 176 

105.  Closure  of  a  triangular  defect  by  the  method  of  Amnion 176 

106.  Closure  of  a  triangular  defect  by  the  second  method  of  Szymonowski 176 

106-A.  Third  method  of  closure  of  triangular  defect  according  to  Szymonowski     .     .     .     .  176 

107.  Closure  of  a  triangular  defect  by  the  method  of  Burow 176 

108.  Second  method  of  closure  of  triangular  defect  according  to  Burow 176 

109.  Closure  of  oval  defect  by  method  of  Lisfranc 176 

110.  Closure  of  oval  defect  by  method  of  Szymonowski 176 

111.  Closure  of  oval  defect  by  method  of  Celsus 176 

112.  Closure  of  oval  defect  by  method  of  Dieffenbaeh 176 

113.  Closure  of  oval  defect  by  double  flap  method 177 

114.  Closure  of  oval  defect  by  method  of  Weber 177 

115.  Closure  of  circular  defect  by  first  method  of  Szymonowski 177 

116.  Closure  of  circular  defect  by  second  method  of  Szymonowski 177 

117.  Closure  of  circular  defect  by  third  method  of  Szymonowski 177 

118.  Closure  of  quadrilateral  defect  by  method  of  Cole 177 

119.  Closure  of  quadrilateral  defect  by  first  method  of  Szymonowski 177 

120.  Closure  of  quadrilateral  defect  by  second  method  of  Szymonowski 177 

121.  Closure  of  quadrilateral  defect  by  method  of  Dieffenbaeh 177 

122.  Closure  of  quadrilateral  defect  by  method  of  Lexer-Bevari 177 

123.  Closure  of  quadrilateral  defect  by  method  of  Burow 177 

124-A.  "Tubed"  pedicle  flap  of  defect  in  face 178 

124-B.  Second   stage   of   operation   of   Fig.   124-A 179 

124-C.  Final  result  of  operation  shown  in  Fig.  124-A 179 

125.  "Tubed"  pedicle  which  has  been  Thiersch  grafted  on  the  raw  surface 180 

126.  The  flap  with  the  "tubed"  pedicle  shown  in  Fig.  125 180 

127.  Method  of  taking  Thiersch  graft 183 

128.  Thiersch  graft  is  cut  with  a  long  amjiutating  knife 183 

129.  The  method  of  Esser  for  preventing  a  sunken  scar 186 

130.  A  modified  Rose  incision  for  a  single  harelip 189 

131.  The  sutures  have  been  placed  and  all  are  tied  except  the  tractor  sutures     ....  189 

132.  An  incision  for  harelip  according  to  the  method  of  Owen 190 

133.  Sutures  in  the  vertical  incision  of  Owen  are  placed 190 

134.  The  last  sutures  are  placed  in  the  operation  of  Owen 190 

135.  Line  of  incision  for  excision  of  nasal  septum 191 

136.  Lines  of  incision  for  double  harelip 192 


]  8  ILLUSTRATIONS 

FIG.  PAGE 

137.  Double  harelij)  (ipci-;itioii  comiileted  excejjt  for  insertion  of  additional  sutures     .     .     .  192 

138.  David  R.,  ten  montlis  old.    Photograiili  taken  liefoi'e  operation 193 

139.  David  E.,  shown  in  Fig.  13S.     Photograpli  taken  four  montlis  after  opeiaf ion     .     .     .  193 

140.  Bessie  H.,  three  weeks  of  age.    Harelip  and  complete  cleft  of  palate 193 

141.  Same  patient  shown  in  Fig.   140.     I'liotograph  taken  two  years  and   seven   months 

after  the  operation 193 

142.  Herbert  T.,  age  seven  months.    Double  harelip  and  cleft  palate 194 

143.  Same  i^atient  shown  in  Fig.   142.     Photograph  taken   two  years  and   tluee   months 

after   ojieration r     .     .     .  1^*4 

144.  Lines  of  incision  for  relaxation  in  operation  for  cleft  palate 197 

145.  Cleft   palate   operation   completed 197 

14G.  Lines  of  incision  for  repair  of  upper  lip  by  method  of  Denonvilliers 198 

147.  Operation  of  Denonvilliers  completed 198 

148.  Operation  of  Sedillot  for  repair  of  the  upper  lip 199 

149.  Lines  of  incision  for  repair  of  defect  in  upper  lip  by  method  of  Abbe 199 

150.  The  flap  from  the  lower  lip  has  been  turned  into  the  defect  in  the  upper  lip.  ac- 

cording to  Abbe 199 

151.  The  pedicle  has  been  cut,  and  the  operation  of  Abbe  completed 199 

152.  Lines  of  incision  for  the  operation  of  Gurdon  Buck  in  repair  of  the  upper  Up     .     .  200 

153.  Operation  of  G-urdon  Buck  completed 200 

154.  V-shaped  excision  for  cancer  of  the  lower  lip , 201 

155.  V-shaped  incision  closed  with  sutures 201 

156.  Lines  of  incision  for  operation  of  Bruns  in  repair  of  lower  lip 201 

157.  Operation  of  Bruns  completed 201 

158.  Lines  of  incision  for  operation  of  Estlander  for  repair  of  lower  lip 202 

159.  Operation  of  Estlander  completed 202 

160.  Lines  of  incision  for  operation  of  Dieffenbach  in  repair  of  lower  lip 202 

161.  Operation  of  Dieffenbach  completed 202 

162.  Lines  of  incision  for  "visor"  operation  in  repair  of  lower  lip,  according  to  Viguerte- 

Morgan 203 

163.  Lines  of  incision  for  operation  of  Sedillot  in  repair  of  the  lower  lip 203 

164.  Lines  of  incision  for  second  method  of  Sedillot  in  repair  of  the  lower  lip     ....  204 

165.  Second  method  of  Sedillot  completed 204 

166.  Method  of  securing  a  flap  from  the  arm  for  repair  of  lower  lip 204 

167.  Ultimate  result  after  repair  of  lower  lip  following  injury  from  burn  in  the  patient 

that   is   shown  in  Fig.    166     ...    ^ 204 

168.  Lines  of  incision  for  operation  of  Montet  in  repair  of  angle  of  the  mouth     ....  205 

169.  Lines  of  incision  for  the  operatio]i  of  Szymonowski  for  repair  of  the  angle  of  the 

mouth 205 

170.  Oj^eration  of  Szymonowski  completed 205 

171.  Lines  of  incision  for  correction  of  downward  contraction  of  the  angle  of  the  mouth  206 

172.  Completion  of  operation  for  correction  of  downward  displacement  of  angle  of  the 

mouth 206 

173.  Lines  of  incision  for  operation  of  Schulten  for  repair  of  mucosa  of  lower  lip     .     .     .  206 

174.  Section  showing  location  of  flap  taken  from  the  upper  lip 206 

175.  The  flap,  according  to  Schulten,  has  been  sutured  into  position 206 

176.  Lines  of  incision  for  repair  of  mucosa  of  lower  lip  according  to  the  method  of  Nelaton 

and  Ombredanne 207 

177.  Operation  of  Nelaton  and  Ombredanne   completed 207 

178.  Lines  of  incision  for  reconstruction  of  vermilion  border  of  lower  lip 207 

179.  The  vermilion  border   of  the  lower  lip   reconstructed   according  to   the   method   of 

Tripier 207 


ILLUSTRATIONS  19 

FIG.  PAGE 
ISO.   Koi'onsti'iU'tinn   of  defrt-t    in   llic   lowci'  j;i\v  l)y  ;i   iicdiclc   ll;i|)   incliidinji'  ;i    jKirtioii   iif 

tlio  clavicle 208 

Isl.   Jjiiios  of  incision  for  rt'imir  of  dofcM-t  in  the  niidliiio  of  lower  jaw 208 

182.   Tlio  llap  witli  its  jjraflod  bono  is  tnrni'd  into  tho  defect  of  the  lower  jaw      ....  208 

IS.').  Lines  of  incision  for  repair  of  defect  in  the  check  and  angle  of  the  mouth     ....  209 

154.  Tiie  ilap  indicated  in  the  previous  figure  has  been  dissected  and  placed  in  the  defect  209 
IS.").  Line  of  incision  for  rel(>asing  contraction  of  tlie  np|H'r  lid  according  to  operation  of 

Gillies 211 

ISO.  Dissection   of   contraction   of   ujijicm'    lid     . 211 

1S7.  The  upper  lid   is  freed   and  turned   down 211 

155.  Thiersch  giaft  is  placed  on  a  mold  of  wax  (Gilli?s)          211 

ISO.   The  mold,  with  the  Thiersch  graft  placed  with  the  epithelium  next  to  the  mold,  is 

sutured   into   the   raw   surface 211 

190.  The  sutures  which  catch  the  skin  of  the  lids  and  the  graft  are  tied 211 

191.  The  late  result  of  operation  of  Gillies  for  eversion  of  u^iper  lid     , 212 

192.  Lines  of  incision  for  the  Wharton  Jones  operation  for  ectropion  of  the  lower  lid     .  212 

193.  The   operation  of  Wharton   Jones  completed 212 

194.  Lines  of  incision  for  operation  of  Dieffenbaeh  for  ectropion  of  lower  lid     ....  212 

195.  Operation  of  Dieffenbaeh  completed -12 

190.  Lines  of  incision  for  operation  of  Knapp  for  repair  of  lower  lid 21.3 

197.  Operation  of  Knapp  completed 21.3 

198.  Operation  of  Monks  for  repair  of  lower  lid 213 

199.  The  flap  is  freed  and  caught  with  forceps 213 

200.  The   operation    of   Monks   completed 213 

201.  Operation  of  Gibson  for  repair  of  lower  lid 215 

202.  Thiersch  graft  is  placed  in  position 215 

203.  The  growth  on  the  lower  lid  is  excised 215 

204.  Ten  days  after  the  grafting  the  flap  Is  drawn  over  the  defect  in  the  lower  lid     .     .     .  215 

205.  The   operation   of   Gibson  completed 215 

206.  Lines  of  incision  for  operation  of  Syndacker-Morax  for  repair  of  both  lids     .     .     .  216 

207.  The  pedicle  has  been  sutured  into  position  to  the  upper  lid 216 

208.  Deformity  following  a  burn  in  a  boy,  J.  M 217 

209.  The  patient  shown  in  Fig.  208 217 

210.  Patient   shown   in   Fig.   209 217 

211.  Excision  of  V-shaped  section  of  lower  lid  for  senile  ectropion 218 

212.  Lengthening  the  outer  canthus  of  the  eye  according  to  von  Ammon-Agnew     .     .     .  218 

213.  Narrowing  the  outer  canthus  of  the  eye  according  to  Walthers 218 

214.  Eeconstruction  of  the  eyebrow  by  turning  down  a  flap  from  the  forehead     ....  219 

215.  Reconstruction  of  the  eyebrow^  by  turning  down  a  flap  from  the  temporal  region     .  219 

216.  Painful  and  contracted  scar  left  after  removal  of  an  eye 220 

217.  A  flap  dissected  from  the  abdomen  according  to  the  method  of  J.  S.  Davis     .     .     .  220 

218.  The  abdominal  flap  has  been  sewed  to  the  incision  in  the  hand 221 

219.  The  painful  scar  in  the   eye   socket  has  been   removed  and  the   flap   on   the   hand 

sutured  in  position 221 

220.  The  operation  of  Monks  for  prominent  ears 222 

221.  Operation  of  Luckett  for  prominent   ears 222 

222.  Method  of  reconstructing  ears  that  are  too  large 222 

223.  Lines  of  incisions  for  the  operation  of  iSzymonowski  for  reconstruction  of  the  ear     .  223 

224.  The  flap  is  dissected  up  and  folded  on  itself 223 

225.  Lines  of  incision  at  A   and  B  show  outlines  of  flap 223 

226.  Faps  A  and  B  are  raised  and  the  extremities  of  the  new  ear  are  brought  forward     .  223 

227.  The  flaps  A  and  B  are  transferred  posteriorly 223 


20  ILLUSTRATIONS 

FIG-  PAGE 

228.  Lines  of  incision  for  operation  of  Roberts  for  ]-eeonstructing  tlie  ear 224 

229.  The  flap  is  dissected  up  and  attached  to  tlie  body  of  the  ear 224 

230.  Tlie  lobe  for  the  ear  is  dissected  up  and  attached  to  the  body  of  the  ear     ....  224 

231.  Lines  of  incision  for  operation  of  Esmarch  for  reconstruction  of  a  la  of  nose     .     .     .  225 

232.  The  pedicled  flap  is  turned  into  position 225 

233.  Operation  of  Esmarch  completed 225 

234.  Lines  of  incision  for  operation  of  Dieft'cnbacli  for  defect  of  ala  of  nose 225 

235.  Operation  of  Dieffenbach  completed 225 

236.  Photograph  showing  defect  in  the  nose  caused  by  application  of  paste 22G 

237.  Lines  of  incision  for  correcting  defect  shown  in   Fig.  236 226 

238.  The  small  bridge  of  tissue  is  cut  away 226 

2.59.  A  flap  is  formed,  constituting  the  lower  border  of  the  ala 226 

240.  A  flap  from  the  mucosa  of  the  septum  as  indicated  in  Fig.  238  is  turned  into  the 

wound 226 

241.  The  pedicle  to  this  flap  is  severed  and  the  flap  sutured  into  position 226 

242.  A  flap  from  the  forehead  has  been  turned  into  a  defect  in  the  tip  of  the  nose     .     .227 

243.  Lines  of  incision  for  operation  of  Xelaton  for  correction  of  defect  of  the  ala     .     .  227 

244.  The  operation  of  Nelaton  completed 227 

245.  Lines  of  incision  for  the  operation  of  Lexer  for  the  restoration  of  the  columna     .     .  228 

246.  A  flap  is  taken  from  the  mucous  surface  of  the  under  lip 228 

247.  The  operation  of  Lexer  completed 228 

248.  Lines  of  incision  for  operation  of  J.  S-.  Davis  for  restoration  of  the  columna     .     .     .  228 

249.  The  flaps  outlined  in  the  previous  figure  are  turned  into  position 228 

250.  Lines  of  incision  for  the  operation  of  Langenbeck  for  reconstruction  of  the  nose     .  229 

251.  Lines  of  incision  for  the  operation  of  Labat-Blasius  for  reconstruction  of  the  nose     .  230 

252.  Flaps  outlined  in  the  preceding  illustration  have  been  dissected  and  sutured  to  con- 

struct the  alae  of  the  nose 230 

253.  Lines  of  incision  for  ox^eration  of  Keegan  for  reconstruction  of  the  nose     ....  230 

254.  Lines  of  incision  for  operation  of  Thiersch  for  reconstruction  of  the  nose     ....  231 

255.  Lines  of  incision  for  operation  of  Israel  for  reconstruction  of  the  nose  by  a  flap 

from  the  forearm 232 

256.  The  flap  from  the  forearm  has  been  dissected  free  and  is  sutured  into  piosition  on 

the  face 232 

257.  Dissection  of  a  flap  from  the  finger  as  the  first  stage  in  the  operation  of  Baldwin 

for  reconstruction  of  the  nose  from  a  finger 233 

258.  Lines  of  incision  for  the  operation  of  Joseph  for  reconstruction  of  the  nose     .     .     .  233 

259.  The  denudation  according  to  .Joseph  for  the  elevation  of  a  drooping  ala     ....  235 

260.  Operation  as  outlined  in  the  preceding  illustration  is  completed 235 

261.  Lines  of  incision  for  operation  of  Diettenbach  for  elevation  of  one  side  of  the  nose     .  235 

262.  Operation  of  Dieffenbach  completed 235 

263.  Lines  of  incision  for  operation  of  Pirogoff  for  lowering  the  tip  of  the  nose     .     .     .  235 

264.  Operation  of  Pirogoff'  completed 235 

265.  Lines  of  incision  for  operation  of  KoUe  for  reconstruction  of  nostrils 235 

266.  Operation   of  Kolle   completed 235 

267.  Lines  of  incision  for   closure   of   defect  in   frontal   sinus   of   tlie   patient    shown   in 

Fig.    270 236 

268.  After  suturing  the  edges  of  flaps  C  and  D,  flaps  A  and  B  are  freed 236 

269.  Flaps  A   and  B   are  sutured  as   shown 236 

270.  Photograph  of  patient  E.  W.  S.,  taken  before  operation 236 

271.  Photograph  of  E.  W.  S.,  two  weeks  after  operation 236 

272.  The  incisions  for  repair  of  defect  in  the  frontal  sinus  when  there  is  no  depression     .  237 

273.  The  forehead  has  been  mobilized  and  the  wound  is  sutured  with  a  suljcutieular  stitch  237 


ILLUSTRATIONS  21 

riG.  PAGE 

274.  Pholoi>T;ii»li   of  jiatiriit   S.   IT.,   two  weeks  after  operation   as  deseribocl  in  llie   two 

preceding  ligures 237 

275.  Lines  of  incision  for  e.Kcision  of  a  benign  tnnior  of  tlie  face 239 

276.  The  growth  has  been  exeised  and  the  skin  and  subcntaneous  tissnc  are  thoroughly 

mobilized 239 

277.  The   superficial  fascia  and  fit  is  approximated  with  a   continnous  suture   of  plain 

catgut 239 

27S.  The  deep  layer  of  tlie  skin  is  united  witli  a  subeutienlar  suture  of  fine  silkworm  gut  239 

279.  The  epithelial  layers  are  united  with  a  superficial  stitch  of  very  fine  silkworm  gut 

or  of  arterial   silk 239 

280.  Method  of  Deguise  for  closing  salivary  fistula  of  Steno  's  duct 240 

281.  Operation  of  Grouse  for  closure  of  salivary  fistula  of  the  parotid 241 

282.  The  pedicle  of  a  flap  of  mucosa  is  formed  from  within  the  mouth 242 

283.  The  pedicle  of  mucosa  with  its  base  backward  has  been  brought  through  with  the 

forceps 242 

284.  The  operation  of  Sedillot  for  excision  of  the  tongue 244 

285.  Liue  of  incision  for  operation  of  Ashhurst  for  excision  of  the  tongue 245 

286.  A  block  dissection  of  the  upper  neck  is  made 246 

287.  The  incision  has  been  continued  to  the  cavity  of  the  mouth 247 

288.  Liue  of  incision  in  operation  of  V.  P.  Blair  for  excision  of  tongue  in  advanced  cancer  249 

289.  The  dissection  of  the  neck  is  begun  and  the  facial  vessels  are  doubly  clamped  and 

divided 250 

290.  Operation  of  Blair   completed,   except   suturing  the   wound         251 

291.  Lines  of  incision  for  op)eration  of  Weber  for  excision  of  upper  jaw 252 

292.  Lilies  of  incision  for  operation  of  Binnie  for  excision  of  the  ux^per  jaw 253 

293.  Eeflection  of  flap  in  operation  of  Binnie  for  excision  of  upper  jaw 253 

294.  Operation  of  Y.  P.  Blair  for  correction  of  retracted  chin 255 

295.  The  line  of  incision  of  the  lower  jaw  is  shown 255 

296.  The  ramus  of  the  lower  jaw  is  completely  divided 256 

297.  The  line  of  incision  for  approach  to  the  temporomaxillary  joint  according  to  J.  B. 

Murphy 257 

298.  Lines  showing  the  excision  of  bone  for  the  Esmarch  operation 258 

299.  Incision  for  resection  of  second  division  of  the  fifth  nerve  from  within  the  mouth     .  259 

300.  Method  of  Rinkenberger  for  cerebral  localization 265 

301.  "Cross  bow"  incision  of  Gushing  for  exposure  of  the  cerebellum 267 

302.  Lines  of  incision  for  operation  for  exposure  of  the  dura  and  brain  after  an   old 

depressed  fracture 269 

303.  The  adherent  dura  and  tissues  are  removed  and  the  brain  is  exposed 2/0 

304.  A  fatty  fascia  flap  from  the  thigh  has  been  sutured  over  the  defect  in  the  dura     .  271 

305.  The  flap  of  pericranium  is  transferred  over  the  fatty  fascia  graft 272 

306.  Photograi)h  of  a  baby  with  meningocele  in  the  lower  part  of  the  occipital  bone     .     .  277 

307.  Lines  of  incision  for  excision  of  the  meningocele  shown  in  preceding  figure     .     .     .  277 

308.  A  cuff  of  scalp  is  turned  back,  the  opening  in  the  skull  is  thoroughly  exposed     .     .  278 

309.  The  neck  of  the  sac  is  ligated 278 

310.  The  flap  of  pericranium  is  sutured  into  position 279 

311.  Line  of  incision  for  subtemporal  decompression 279 

312.  The  fibers  of  the   temporal   muscle   are    separated   and   the   pericranium   and   skull 

are  exposed 280 

313.  The  skull  is  perforated  with  a  drill  or  burr 280 

314.  The  dura  is  incised  after  picking  it  up  with  the  point  of  a  needle 281 

315.  The  dura  has  been  split  and  the  bulging  brain  is  exposed 281 


22  ILLUSTRATIONS 

^^«-  PAGE 

316.  The  woiincl  is  closed  by  suturing  first  tlie  fibers  of  tlie  teuipoi-al  unisc-le,   then  tlie 

galea^  and  finally  the  skin 282 

317.  Lines  showing  the  incision  in  tlie  operation  of  Fra/.ier  for  removal  of  tlie   sensory 

root  of  the  gasserian  ganglion 284 

318.  The  flails  are  reflected  and  the  skull  is  perforated  with  a  burr 284 

319.  The  sensory  root  of  the  ganglion  is  exposed  and  is  about  to  be  avulsed 285 

320.  Operation  of  Adson  showing  ligation  of  the  middle  and  exposure  of  the  sheath  of 

the  j)osterior   sensory   root 286 

321.  The  posterior  sensory  root  is  divided  in  its  sheath 286 

322.  The  incision  for  laminectomy  according  to  Frazier 291 

323.  Spinous  processes  have  been  partly  removed 292 

1^24.  The  dura  of  the  cord  is  incised 293 

325.  The  dura  has  been  incised  and  the  cord  is  exposed 294 

326.  The  dura  is  sutured 29o 

327.  The  sac  of  a  spina  bifida  has  been  exposed  by  a  U-shaped  flap.     (Frazier.)      .     .     .  298 

328.  The  stump  of  the  sac  is  being  sutured 299 

329.  A  fascia  flap  is  formed  to  turn  onto  the  stump  of  the  sac 299 

330.  The  lines  of  incision  for  a  flap  of  fascia  to  slill  further  cover  in  the  defect     .     .     .  299 

331.  The  flap  of  fascia  outlined  in  the  preceding  figure  is  being  sutured  in  place     .     .     .  299 

332.  Operation  of  Babcock  for  sj)ina  bifida 300 

333.  Second  stage  of  Babcock 's  operation 301 

334.  Section  showing  the  various  layers  of  tissues  that  are  sutured  in  the  operation  of 

Babcock  for  spina  bifida 302 

335.  Cross   section   showing  the   relations   of   the   cysts   and   fistulas   of   the   thyroglossal 

tract,  according  to  Sistrunk 306 

336.  The  middle   segment   of   the  hyoid  bone  is   removed   and   the  thyroglossal  tract   is 

dissected 307 

337.  The  dissection  has  been  completed,  and  the  foramen  cecum  is  exposed 307 

338.  A  completed  block  dissection  of  one  side  of  the  neck 315 

339.  Lines    of    incision    for    laryngectomy 318 

340.  The  larynx  has  been  exposed  and  partly  mobilized 319 

341.  The  trachea  has  been  divided  and  brought  to  the  skin 320 

342.  The  laryngectomy  completed 321 

343.  Photograph  of  a  patient  with  a  large  diffuse  lipoma  of  the  neck 325 

344.  Photograph  of  patient  shown  in  jjreceding  illustration  a  few  weeks  after  operation 

for  removal  of  difl'use  lipoma     .     .~ 325 

345.  Exposure  of   goiter 328 

346.  The  goiter  has  been  partially  mobilized 329 

347.  Line  of  incision  for  amputation  of  distal  phalanx  of  finger 337 

348.  Showing  the  method  of  forming  long  palmar  flap  in  amputation  of  finger     ....  337 

349.  Amputation  of  the  finger 338 

350.  Amputation  of  the  finger  by  different  methods 339 

351.  Disarticulation  of  the  hand 340 

352.  Amputation  of  the  hand 340 

353.  Lines  of  incision  for  amputation  of  forearm 342 

354.  Lines  of  incision  for  amputation  at  elbow  by  posterior  elliptical  flap 344 

355.  Lines  of  incision  for  amputation  of  the  arm 345 

356.  Wyeth's  method  of  hemostasis  for  amputation  at  shoulder 347 

357.  Lines  of  incision  for  amputation  of  shoulder 348 

358.  Lines  of  incision  for  excision  of  the  wrist 352 

359.  Lines  of  incision  for  excision  of  elbow 3,52 

360.  Lines  of  incision  for  excision  of  the  shoulder  joint 354 


ILM'STKATIONS  23 

FIG.  I'A'iK 

,".()I.   LiiU's  (if  incision   for  i-('nio\;il  ol'  din nioiid  sli;i |ii'il  area  at  ciliow 355 

l\&2.  Wotlioil  of  Doiranci'    fni'  incision  of  foloii  and  plnciMg  ot'  diaiiiaf^e .550 

363.  Lino  of  im-ision   for  opciation   for  webbed  fingers,  palmar  surface 359 

',l(U.  Line  of  incision  for  operation  for  webbed  fingers,  dorsal  surface -5*50 

365.  The  flajis  as  outlined  in  the  two  preceding  drawings  have  been  dissected  and  are 

being  sutured "561 

366.  Method  of  applying  the  tendon  suture  of  Frisch 362 

367.  Transplantation  of  tendon  of  the  flexor  carpi  radialis  for  paralysis  of  the  extensor 

muscles  of  the  forearm  according  to  J.  B.  Murphy 363 

368.  A  skin  incision  is  made  and  the  tendon  is  drawn  thvougli 364 

369.  xV  third  incision  is  made  on  the  back  of  the  wrist 365 

370.  Last  stage  of  operation  shown  in  three  preceding  figures 366 

371.  Placing  of  silk  threads  on  anterior  surface  of  arm  and  forearm  to  relieve  swelling 

of   the   upper   extermity.      (Handley.) 367 

372.  Placing  of  silk  threads  on  the  posterior  surface  of  the  arm  and  forearm     ....  367 

373.  Lines  of  incision  for  operation  of  Kondolcon  along  outer  border  of  the  upper  ex- 

tremity       368 

374.  Lines  of  incision  for  operation  of  Kondoleon  along  inner  border  of  the  upper  ex- 

tremity       368 

375.  Lines  of  incision  for  amputation  of  the  toe 372 

376.  Lines    of   incision    for   amputation   of   the    tarso-metatarsal   joint    (Lisfrane's    am- 

putation)        373 

377.  Lines  of  incision  for  amputation  of  Syme  at  the  ankle 375 

378.  Lines  of  incision  for  amputation  of  leg.    (Hey.) 377 

379.  Lines  of  incision  for  amputation  of  leg.     (Farabeuf.) 378 

380.  Lines  of  incision  for  amputation  of  Stephen  Smith  at  the  knee  joint 378 

381.  Lines  of  incision  for  amputation  of  the  thigh 381 

382.  Lines  of  incision  for  amputation  of  the  hip  and  thigh 381 

383.  The  method  of  Wyeth  for  hemostasis  in  amputation  at  the  hip  joint 382 

384.  Lines  of  incision  for  amputation  at  the  hip  joint  by  the  anterior  racket  incision     .     .  384 

385.  Open  tenotomy  by  the  zigzag  or  step  method 386 

386.  Points  of  entrance  of  the  tenotome  in  subcutaneous  tenotomy  of  the  plantar  fascia 

(Soutter) 386 

387.  Transplantation  of  the  tendon  of  the  peroneus  muscle 389 

388.  Tendon  and  muscle  have  been  drawn  through  the  second  incision  and  are  ready  to 

be  transj)lanted 389 

389.  The  tendon  of  the  peroneus  has  been  transplanted 390 

390.  Transplantation    of    the    tendon    of    the   peroneus    longus    into    the    tendo    Achillis, 

(Jones) 392 

391.  The  peroneus  tendon  divided  and  the  tendo  Achillis  is  being  split 392 

392.  The  peroneus  tendon  is  drawn  through  the  slit  in  the  tendo  Achillis 393 

393.  The  peroneus  tendon  is  drawn  through  the  second  slit  in  the  tendo  Achillis     .     .     .  394 

394.  Excision  of  a  diamond-shaped  area  of  skin  on  the  dorsum  of  the  foot     .     .     .     .     .  395 

395.  Exposure  of  tendon  of  the  extensor  proprius  hallucis 395 

396.  Drilling  a  hole  in  the  head  of  the  metatarsal  bone  for  transplantation  of  the  extensor 

proprius  hallucis 396 

397.  The  method  of  drawing  a  tendon  through  a  drill  hole  in  the  head  of  the  metatarsal 

bone ^"^^ 

398.  Transplantation  of  tendon  of  the  biceps  femoris 398 

399.  A  tunnel  has  been  made  and  the  biceps  tendon  is  to  be  drawn  through  to  the  second 

incision 399 

400.  The  tendon  of  the  cpuidriceps  has  been  split  and  the  tendon  of  the  biceps  is  drawn 

through 400 


24  ILLUSTRATIONS 

FIG.  PAGE 

401.  Correction  of  club  foot 402 

402.  Line  of  incision  for  the  oj^eration  of  Ober  for  correction  of  club  foot 402 

403.  Mobilization  of  the  periosteum  and  ligaments  in  the  operation  of  Ober 40.3 

404.  Mobilization  of  anterior  portion  of  periosteum  and  ligaments  in  the  operation  of  Ober  404 

405.  Lines  of  incision  for  operation  for  ingrowing  toe  nail 406 

406.  Insertion  of  braided  silk  for  correction  of  flail  ankle  joint.     (Bi-adford.)      ....  408 

407.  The  drill  has  entered  the  tibia 408 

408.  The  drill  hole  has  been  made  in  the  tibia  and  the  silk  is  being  pulled  through     .     .     .  409 

409.  A  tunnel  has  been  made  on  the  outer  side  of  the  foot,  and  the  silk  is  being  pulled 

through  the  tunnel 409 

410.  The  loop  is  being  pulled  through  the  drill  hole  in  the  tarsus 409 

411.  A  tunnel  has  been  made  on  the  inner  side  of  the  foot  and  the  second  end  of  the  silk 

is  being  pulled  through  to  the  first  end 409 

412.  The  knots  have  been  tied 410 

413.  Lines  of  incision  for  operations  about  the  ankle  joint 411 

414.  Incision  for  bone  grafting  in  intractable  club  foot 412 

415.  Club  foot  has  been  straightened  and  is  ready  to  receive  the  bone  graft 412 

416.  Osteotomy  of  the  neck  of  the  femur  with  the  saw 419 

417.  Osteotomy  of  the  internal  condyle  of  the  femur  for  knock  knee.     (Ogston.)      .     .     .  419 

418.  Osteotomy  of  the  internal  condyle  of  the  femur  for  knock  knee.     (Eeeves.)      .     .     .  419 

419.  The  dark  portion  of  the  involucrum  shows  the  part  to  be  removed 424 

420.  Another  method  of  avoiding  cavity  formation  in  the  bone 425 

421.  The  mobilized  wall  of  the  involucrum  shown  in  the  preceding  figure 425 

422.  Lines  of  incision  for  tiap  to  fill  defect  in  the  bone  (von  Eiselsberg) 426 

423.  The  flap  has  been  mobilized  and  is  ready  to  be  turned  down  in  position 426 

424.  The  flap  is  sutured  in  position 426 

425.  Lines  of  incision  for  operation  of  Kondoleon  on  outer  surface  of  lower  extremity     .  427 

426.  Lines  of  incision  for  operation  of  Kondoleon  on  inner  surface  of  lower  extremity     .  427 

427.  Lines  of  incision  for  excision  of  varicose  veins  of  the  leg 429 

428.  Mobilizing  and  stripping  the  varicose  vein.     (C.  H.  Mayo.) 430 

429.  A  method  of  drainage  of  empyema  by  negative  pressure 438 

430.  A  rubber  tube  for  drainage  of  empyema 489 

431.  Operation  of  Estlander  for  chronic  empyema 440 

432.  The  muscle  flap  is  dissected  and  is  sutured  into  the  wound 441 

433.  The  skin  flap  is  sutured  in  position 442 

434.  Diagram  showing  method  of  injecting  local  anesthetic  for  operation  on  abscess  of 

the  lung.     (Bevan.) 444 

435.  An  incision  has  been  made  down  to  the  parietal  pleui-a,  and  the  wound  is  packed 

with  gauze 445 

436.  Several   days  later   the   abscess   is   opened   with   an   electric    cautery   Avhich   follows 

the  aspirating  needle 445 

437.  The  lines  of  incision  for  closure  of  a  fistula  following  abscess  of  the  lung.     (Bevan.)  446 

438.  The  ribs  have  been  resected  and  the  fistulous  tract  is  being  dissected 447 

439.  The  dissection  of  the  fistulous  tract  has  been  almost  completed 448 

440.  The  line  of  incision  for  excision  of  a  lobe  of  the  lung.     (Robinson.) 449- 

441.  The  lung  has  been  exposed  and  the  adhesions  to  the  diaphragm  are  being  separated  450 

442.  The  lobe  of  the  lung  is  excised  after  clamping  the  pedicle 451 

443.  Lines  of  incision  for  the  operation  of  Trendelenburg  for  pulmonary  embolism     .     .  454 

444.  Incision  into  the  pulmonary  artery,  which  is  held  open  by  self-retaining  forceps     .  445 

445.  Forceps  are  withdrawing  the  embolism  from  the  pulmonary  artery 456 

446.  The  incision  in  the  pulmonary  artery  is  closed  by  a  clamp  and  sutured  with  fine  silk  457 

447.  Incision   of   Dean  Lewis   for   removal   of   the   mammary   gland   in   intracanalieular 

papilloma _  ...  464 


ILLUSTRATIONS  25 

PIG.  PA«E 

448.  The  maniniai^v  gland  is  being  freed 465 

440.  The  mammary  gland  has  been  excised  and  pursostring  sutures  are  ins:?rted  in  the 

surrounding  fat -iOG 

450.  The  pursestring  sutures  have  been  tied,  so  obliterating  tlie  cavity  left  by  removal 

of  the  mammary  gland 466 

451.  lanes  of  incision  for  operation  of  Jackson  for  cancer  of  the  breast 469 

452.  Lines  of  incision  for  operation  of  Rodman  for  cancer  of  the  breast 470 

453.  The  axilla  is  exposed  and  dissected  from  above  downward 471 

454.  The  incisions  are  extensively  undermined  in  order  to  remove  as  much  of  the  sub- 

cutaneous  fat   and   fascia   as   possible 473 

455.  The  breast  with  its  adjoining  structures  has  been  removed  in  one  mass     ....  474 

456.  Photograph  of  patient  of  the  author  on  whom  the  Rodman  operation  was  done     .     .  475 

457.  Line  of  incision  for  exposure  of  the  inguinal  canal  in  the  Bassini  operation  for  in- 

guinal  hernia 480 

458.  The   external  inguinal   ring   is   exposed 481 

459.  The  inguinal  canal  is  exposed  by  splitting  the  libers  of  the  external  oblique     .     .     .  482 

460.  The  sae  is  being  freed 483 

461.  The  neck  of  the  sac  is  ligated 484 

462.  The   cord  is  mobilized 485 

463.  The  conjoined  tendon  and  the  internal  oblicjue  and  transversalis  muscles  are  sutured 

to   Poupart's  ligament   beneath   the   cord 486 

464.  The  incision  in  the  aponeurosis  of  the  external  oblique  is  closed  with  a  continuous 

lock    stitch 487 

465.  The  skin  is  closed  with  a  continuous  mattress  suture  of  fine  tanned  catgut     .     .     .  488 

466.  A  flap  is  formed  from  the  sheath  of  the  rectus  muscle,  according  to  Halsted     .     .  488 

467.  The  fibers  of  the  rectus  muscle  can  also  be  transplanted  according  to  the  suggestion 

of   Bloodgood 489 

468.  Exposure  of  the  neck  of  the  sac  from  within  the  peritoneal  cavity.      (LaRoque.)      .  490 

469.  Suturing  the  neck  of  the  sac  from  within  the  peritoneal  cavity 490 

470.  Method  of  inverting  a  large  sac  from  within  the  peritoneal  cavity 492 

471.  Suturing  the  neck  of  a  large  sac  from  within  the  peritoneal  cavity 492 

472.  Exposure  of  neck  of  the  sac  of  a  femoral  hernia  by  the  method  of  Seelig  and  Tuholski  495 

473.  The  neck  of  the  sac  is  ligated,  the  sac  excised,  and  sutures  are  placed  to  obliterate 

the    femoral    canal 496 

474.  Lines  of  incision  for  reconstructing  Poupart's  ligament 498 

475.  The  flap  has  been  sutured  into  x^osition  so  as  to  reinforce  Poupart  's  ligament     .     .  498 

476.  The  neck  of  the  sac  of  an  umbilical  hernia  is  exposed  and  is  ready  for  incision     .     .  500 

477.  Mattress  sutures  for  imbrication  of  the  margins  of  the  opening  in  the  aponeurosis 

of  the  abdominal  wall  are  placed 500 

478.  The  mattress  sutures  have  been  tied  snugly 501 

479.  An   epigastric   hernia   is   exposed 504 

480.  Lines    for    abdominal    incisions 509 

481.  The  incision  of  Judd  for   double  inguinal  hernia 513 

482.  Method  of  closing  incisions  above  the  umbilicus •  517 

483.  Exposure  of  the  cystic  duct  in  cholecystectomy 523 

484.  Double  ligation  and  clamping  of  the  cystic  duct 523 

485.  The  cystic  artery  has  been  clamped  and  the  gall  bladder  is  being  dissected  out  from 

below  upward 524 

486.  The  cystic  artery  has  been  tied  and  the  bed  of  the  gall  bladder  is  sutured     .     .     .  525 

487.  A  rubber  tube  is  carried  to  the  stump  of  the  cystic  duet 526 

488.  The  author's  method  of  cholecystenterostomy 531 

489.  A  double  row  of  sutures  unites  the  gall  bladder  to  the  duodenum 532 

490.  Excision  of  the  head  of  the  pancreas.      (Cofl'ey.) 536 


"26  ILLUSTRATIONS 

FIG.  PAGE 

491.  Second  stage  of  excision  of  head  of  pancreas 537 

492.  Transi^lantation  of   common  bile   duct.      (Coffey.) 537 

493.  The  common  bile  duet  is  sutured  in  a  new  position 537 

494.  The  transplantation  of  the  common  duct  is  complete     . 538 

495.  A  sectional  view  of  the  transplanted  duct 538 

496.  Exposure  of  the  pedicle  of  the  spleen  in  splenectomy.      (Balfour.) 540 

497.  Another  method  of  treating  the  pedicle  of  the  spleen.      (Balfour.) 541 

498.  Shortening  the  gastrohepatie  omentum  in  ^^tosis  of  the  stomach 544 

499i  The  gastrohepatie  omentum  is  shortened  and  sutures  are  jalaced  in  the  gastrocolic 

omentum 545 

500.  The  sutures  in  the  gastrocolic  omentum  are  x^laced  and  tied 546 

501'.  Lines  of  incision  for  pyloroplasty  of  Finney 550 

502.  The  margins  of  the  wound  are  being  united  with  a  continuous  lock  stitch     .     .     .  550 

503.  Lines  of  incision  for  the  author's  pyloroj^lasty 552 

504.  Second   stage   of   author's   operation 553 

505.  Correction  of  pocket  formation  with  marked  stenosis 554 

506.  Correction  of  pocket  formation  completed 554 

507^.  Third  stage  of  author's  operation 555 

507B.  Fourth  stage  of  author's  operation 555 

508.  Fifth  stage  of  author's  operation 556 

509.  Sixth  stage  of  author's  operation 557 

510.  Seventh  stage   of   author 's   ojieration     .         558 

511.  Author's  opei'ation  completed       558 

512.  A  roentgenogram  of  a  patient,  Miss  E.  D.  H.,  taken  four  and  one-half  months  after 

this  pyloroplasty  was  done 560 

513.  A  drawing  of  the  stomach  removed  postmortem  from  a  patient   who   died  twenty- 

one  days  after  jDyloroplasty 561 

514.  Diagram  of  the  incisions,  and  direction   of  the  opening  in  posterior  gastroenteros- 

tomy.     (W.   J.   Mayo.)        565 

515.  Posterior   gastroenterostomy.      First   stage 566 

516.  Posterior  gastroenterostomy.     Second  stage 567 

517.  Posterior  gastroenterostomy.     Third  stage 568 

518.  The  gastroenterostomy  of  Eoux  to  prevent  vicious  circle 569 

519.  Incision   through   the   gastrohepatie    and   gastrocolic   omentum    to    expose    ulcer   in 

posterior  wall  of  the  stomach 571 

520.  Gastroenterostomy.      (Polya-Balfour.)        575 

521.  The  duodenal  stump  is  sutured  over  with  a  right  angle  continuous  suture  which  is 

drawn  tight  after  the  clamp  is  removed 576 

522.  Additional  pursestring  sutures  are  added   still  further  to  invaginate   the  duodenal 

stump 576 

523.  The  stomach  is  then  severed  at  its  cardiac  portion  and  a  loop  of  jejunum  is  brought 

uj)   and   sutured   to   the   stomach 577 

524.  The  second  row  of  sutures  is  placed  as  the  second  row  in  gastroenterostomy     .     .     .  578 

525.  Gastrostomy,  according  to  the   Senn  method 580 

526.  Gastrostomy  according  to  the  method  of  Witzel 581 

527.  The  ojieration  of  Eammstedt  for  congenital  pyloric  stenosis 582 

528.  Operation  for  congenital  pyloric  stenosis,  according  to   Strauss 583 

529.  Operation  for  congenital  pyloric  stenosis.     Second  stage 584 

530.  Enterostomy  of  J.  W.  Long 590 

531.  A  rubber  tube  is  introduced  and  held  snugly  Ijy  a  pursestring  suture 591 

532.  The  wound  is  packed  lightly  with  gauze  and  the  tube  fastened  with  adhesive  plaster  592 

533.  Enterostomy,   using   the   principle    of    Coffey 593 

534.  A  catheter  is  inserted  in  the  puncture  and  the  pursestring  suture  is  tied  snugly     .     .  594 


ILLUSTRATIONS  27 

FIG.  PAGE 

5oo.  Tlie    enterostomy    is   completed 595 

536.  Enterostomy  according  to  the  iiiiiiciple  of  Witzid  witlidut  ;in  iiieision  to  the  imieosa  oSHi 

537.  Sections  of  tlie  enterostomies  by  ditt'erent  methods 597 

538.  The  enterostomy  of  John  Young  Brown  with  sliglit  modification 599 

539.  Sigmoidostomy  according  to  tlie  method  of  Mixer 600 

540.  Sigmoidostomy  with  the  bridge  of  skin  sutnred  in  position 601 

541.  Sigmoidostomy    completed 601. 

542.  The   author's  method  of   intestinal  resection 60.j 

543.  Author's  method  of  intestinal   resection.     Second  stage 606 

544.  Author's   method   of   intestinal   resection.      Third   stage 607 

545.  Author's  method  of  intestinal  resection.     Fourth  stage 608 

546.  Author's  method  of  intestinal  resection.     Fifth  stage 608 

547.  Author's  method  of  intestinal  resection  about  completed 609 

548.  Author's  method  of  resection  of  cecum  and  ascending  colon 611 

549.  Author's  method  of  resection  of  cecum  and  ascending  colon.     Second  stage     ...  612 

550.  Longitudinal  section  of  the  completed  operation  with  the  enterostomy  tube  inserted 

through    the    ileum 613 

551.  A   roentgenogram   of  the  yah-e   made  after  resection  of   the   cecum   and  ascending 

colon  by  the  method  just  described 614 

552.  Lines  of  incision  for  excision  of  the  bowel  and  mesentery  in  cancer  of  the  cecum 

or   ascending  colon 615 

553.  Lines  of  incision  for  excision  of  the  bow-el  and  mesentery  in  cancer  of  the  hepatic 

flexure    of    the    colon 615 

554.  Lines  of  incision  for  excision  of  the  bowel  and  mesentery  in  cancer  of  the  splenic 

flexure    of    the    colon 615 

555.  Lines  of  incision  for  excision  of  the  bowel  and  mesentery  in  cancer  of  the  descend- 

ing  colon       615 

556.  Lines  of  incision  for  excision  of  the  bowel  and  mesentery  in  cancer  of  the  sigmoid  616 

557.  Lines  of  incision  for  excision  of  the  bowel  and  mesentery  in  cancer  of  the  terminal 

sigmoid 616 

558.  Meckel's  diyerticulum  in  the  lower  ileum 619 

559.  Lateral  anastomosis  of  the  intestine 620 

560.  Lateral  anastomosis  between  the  jejunum  and  dilated  duodenum  for  obstruction  at 

the  terminal   duodenum 621 

561.  The  skin  incision  for  the  McBurney  muscle  splitting  operation 624 

562.  The  aponeurosis  of  the  external  oblique  is  split  in  the  direction  of  its  fibers     .     .     .  624 

563.  The  aponeurosis  of  the  external  oblique  has  been  split  and  drawn  aside  with  retractors  625 

564.  The  fibers  of  the  internal  oblique  and  transyersalis  are  held  apart  with  retractors     .  625 

565.  The  peritoneum  is  closed  with  a  pursestring  suture  or  a  continuous  mattress  suture  626 

566.  The  fibers  of  the  internal  oblique  and  transversalis  muscles  are  approximated  by  a 

suture   of  plain   catgut        626 

567.  The  aponeurosis  of  the  external  oblique  is  brought  together  with  a  continuous  lock 

stitch  of  plain  catgut 627 

568.  The  skin  is  closed  with  a  subcuticular  suture  of  fine  tanned  catgut 627 

569.  The  appendix  and  its  mesentery  are  tied  with  tanned  catgut .  628 

570.  The  appendix  is  severed  with  an  electric  cautery 628 

571.  The  eschar  and  the  mucosa  in  the  stump  are  curetted 629 

572.  The  stump  of  the  appendix  is  tied  and  a  pursestring  suture  for  inyagination  of  the 

stumj)   is   placed 630 

573.  A  sectional  view  shows  the  result  of  the  invaginating  method .  630 

574.  The  simple  method  of  treating  the  stump  of  the  appendix 631 

575.  A  sectional  view  showing  the  simple  method  of  treating  the  stump  of  the  appendix  631 

576.  Reproduction  of  illustration  by  Bunts,  showing  diverticulum  following  burying  the 

stump    of    the    appendix 632 


28  ILLUSTRATIONS 

FIG.  PAGE 

577.  Drawing  of  a  clivertieiilinn  that  we  liave  seen  following  burying  the  stump   of  the 

appendix 6.32 

578.  A  roentgenogram  of  late  results  after  appendectomy.     (Case.) 633 

579.  The  Kraske  operation  for  excision  of  the  rectum.     (W.  J.  and  C.  H.  Mayo.)      .     .  641 

580.  The  peritoneum  has  been  opened  and  the  lateral  attachments  of  the  rectum  have 

been    severed 6-i2 

581.  Operation  of  Bevan  for  early  superficial  cancer  of  the  anterior  wall  of  lower  rectum  646 

582.  The  cancer  has  been  exposed  and  is  removed  with  an  electric  cautery 647 

583.  The  posterior  wall  of  the  rectum  is  united  with  interrupted  sutures,  tying  the  knot 

within  the  lumen  of  the  boAvel 648 

584.  The  prolapse  of  the  rectal  mucosa  is  cauterized  with  electric  cautery 649 

585.  Clamp   and   cautery   operation   for  hemorrhoids 656 

586.  Clamp  and  cautery  operation  for  hemorrhoids  completed  with  the  insertion  of  a  tube  657 

587.  A  sinus  in  the  anal  canal.     (E.  H.  Terrell.) 659 

588.  A  large  pocket  or  diverticulum  in  the  anal  canal 660 

589.  Removal  of  the  covering  of  one  of  the  anal  pockets,  according  to  the  method  of 

E.  H.  TerreU 661 

590.  The  incision  of  W.  J.  Mayo  for  operation  on  the  kidney 664 

591.  Nephropexy 665 

592.  The  pelvis  of  the  kidney  has  been  opened  and  a  forceps  is  thrust  through  to  the  cor- 

tex, where  it  grasps  a  soft  rubber  catheter 672 

593.  The  catheter  is  drawn  through  so  that  its  tip  barely  rests  in  the  pelvis  of  the  kidney  673 

594.  A  stricture   of  the  lower   end   of  the   ureter 675 

595.  A  method   of  transplanting  the  ureter 680 

596.  Second  stage  of  transplantation  of  ureter 681 

597.  Cross  section  of  the  first  stage  of  the  suprapubic  prostatectomy  of  Squier     ...  692 

598.  The   finger   has   broken   through   the   prostatic   urethra   and   the   prostate    is   being 

enucleated,  beginning  at  its  apex  on  the  right  side 693 

599.  The  prostate  has  been  removed 694 

600.  The  operation  of  H.  H.  Young  for  cancer  of  the  prostate 696 

601.  Operation  of  H.  H.  Young  for  cancer  of  the  prostate.    Second  stage 697 

602.  Operation  of  H.  H.  Young  for  cancer  of  the  prostate.     Third  stage     ......  698 

603.  Operation  of  H.  H.  Young  for  cancer  of  the  prostate.     Fourth  stage 699 

604.  Operation  of  Lespinasse  for  anastomosis  of  the  vas  and  the  epididymis     ....  702 

605.  Operation  of  Lespinasse  for  anastomosis  of  the  vas  and  epididymis.     Second  stage  702 

606.  Operation  of  Lespinasse  for  anastomosis  of  the  vas  and  epididymis.     Third  stage     .  702 

607.  The  first  stage  of  circumcision     ....  - 707 

608.  The   circumcision   is   completed 707 

609.  The  operation  of  Cantwell  for  epispadias 708 

610.  The   Thompson-EusseE   operation   for   hypospadias 709 

611.  The  flaps  are  dissected  and  are  united,  so  forming  the  new  urethra 710 

612.  The  lower  skin  incision  is  sutured  over  the  new  urethra 710 

613.  The    completed    operation 721 


OPERATIVE  SURGERY 


CHAPTER  I 
GENERAL  CONSIDERATIONS* 

Surgical  operations  are  performed  on  living  tissues  and  must  be  considered 
with  regard  to  physiology  and  pathology  in  the  living  as  well  as  from  an  anatomi- 
cal point  of  view.  Operations  that  look  well  on  a  cadaver  will  sometimes 
be  unsuccessful  on  a  patient.  A  beautiful  operation  that  results  in  the  death 
of  the  patient  is  not  satisfactory  surgery.  AVhile  the  mechanics  of  a  surgical 
operation  is  important,  it  should  not  entirely  dominate  the  situation.  The 
object  of  a  surgical  operation  is  to  save  life,  to  relieve  pain,  and  to  restore 
function,  and  these  three  things  in  the  order  named  should  always  be  kept 
in  mind.  The  technic  of  an  operation  should  be  chosen  not  solely  because  it 
appeals  to  a  mechanical  sense,  but  because  it  is  biologically  correct.  The 
changes  and  reactions  of  tissues  after  operation  must  be  borne  in  mind  when 
selecting  the  technic  for  any  surgical  procedure. 

It  cannot  be  too  often  emphasized  that  surgery  should  be  more  a  science 
than  an  art.  A  surgeon  who  is  a  dexterous  operator  and  who  skilfully  ampu- 
tates a  leg  that  wdth  patience  and  scientific  application  could  be  saved,  is 
merely  a  good  artisan,  and  is  distinctly  inferior  to  the  surgeon  who  could 
save  the  leg  even  though  he  should  be  a  bungling  operator.  The  ideal  is  to 
be  thoroughly  imbued  with  the  principles  of  the  biologic  sciences,  thought- 
fully to  apply  these  principles,  and  at  the  same  time  to  be  mechanically 
skilful. 

The  science  of  anatomy  is  essential  to  the  mechanics  of  surgery.  He 
would  be  a  poor  locomotive  mechanic  who  did  not  understand  the  construc- 
tion of  his  engine ;  and  in  operations  on  the  neck,  for  instance,  a  surgeon  who 
is  ignorant  of  anatomy  would  be  like  the  proverbial  bull  in  a  china  shop. 
A  knowledge  of  anatomy  is  essential  to  good  surgery,  but  in  the  ever  shifting 
problems  of  tissue  repair  and  metabolism,  physiology  is  just  as  necessary. 
The  principles  underlying  an  operation  are  correct  only  if  they  conform  to  the 
laws  of  physiology  and  to  the  laws  of  repair  of  the  tissue  or  organ  that  is  affected. 
If  we  could  get  away  from  blindly  following  what  some  one  says  merely  be- 
cause he  says  it,  and  do  things  because  of  reasons  that  have  sound  biologic 
foundations,  we  should  undoubtedly  do  work  more  satisfactory  to  our  patients 
and  to  ourselves. 

Let  us  take  an  illustration  from  the  practical  work  of  a  surgeon  and  see 


*Much   of  this  chapter  is  from   a  paner   entitled   "The  Value  of  Biologic  Principles  in   Surgical   Prac- 
tice."    Horsley,  J.    Shelton:     Jour.  Am.   Med.  Assn.,  May   3,   1919. 

29 


30  operatrt:  si^rgery 

how  tliouglitful  application  of  physiologic  principles  Avould  have  rendered 
a  problem  that  appeared  difficult  easier  to  solve.  Hyperemia  is  connected 
in  one  way  or  another  with  all  surgical  questions,  whether  they  concern 
treatment  of  inflammation  or  repair  of  a  wound.  It  has  long  been  known  that 
blood  is  an  enemy  of  the  tubercle  bacillus,  and  that  obtaining  a  good  supply 
of  healthy  blood  is  the  only  satisfactory  method  of  combating  tuberculosis. 
About  two  decades  ago  when  a  patient  with  tuberculous  peritonitis  and  ascites 
sought  surgical  treatment  he  might  have  been  subjected  to  one  of  several 
procedures.  One  surgeon  would  have  advised  opening  the  abdomen  and 
letting  the  sunlight  in;  another  thought  it  was  best  to  dust  the  intestine  with 
some  special  powder;  still  another  believed  in  drainage  with  a  single  tube, 
others  with  multiple  tubes.  All  these  methods  secured  more  or  less  satis- 
factory results.  Each  surgeon,  seeing  his  patient  recover  after  using  his  own 
method,  earnestly  thought  that  this  was  the  only  correct  procedure.  The 
situation  resembled  very  much  that  described  in  a  poem  in  an  old  school 
reader  in  which  four  blind  men  went  to  see  an  elephant.  One  fell  against 
its  side  and  thought  the  elephant  was  like  a  Avail ;  another  embraced  a  leg 
and  declared  it  resembled  a  tree ;  the  third  grasped  its  tail  and  said  the 
animal  was  constructed  like  a  rope,  and  the  last  felt  a  tusk  and  concluded  that  the 
elephant  was  very  like  a  spear.  The  moral  was  that  though  each  was  partly  in 
the  right  they  all  were  in  the  wrong.  So  all  of  these  surgeons  who  were 
using  different  methods  were  unconsciously  working  on  a  principle  that 
produced  hyperemia,  and  it  was  this  hyperemia,  induced  partly  by  draining 
off  the  fluid  and  so  relieving  pressure,  and  partly  by  handling  the  intestines, 
that  cured  the  tuberculosis.  It  was  many  years,  however,  before  this  fact 
was  acknowledged  by  the  various  partisans. 

The  surgical  treatment  of  slow  or  threatened  gangrene  has  also  been 
much  discussed.  Carrel  and  Guthrie,^  after  two  experiments,  concluded  that 
the  blood  circulation  in  the  leg  of  a  dog  could  be  completely  reversed  within 
six  hours.  They  severed  the  femoral  artery  and  vein  just  below  Poupart's 
ligament  and  united  by  suture  the  cardiac  end  of  the  artery  to  the  distal  end 
of  the  vein,  and  the  distal  end  of  the  artery  to  the  cardiac  end  of  the  vein. 
After  a  few  hours,  when  red  blood  was  seen  returning,  they  assumed  that 
the  circulation  was  reversed.  I  think  it  can  now  be  stated,  however,  that  it 
is  impossible  to  reverse  the  circulation  in  this  manner.  In  a  series  of  experi- 
ments which  have  been  reported  elsewhere,-  we  have  shown  that  when  the 
severed  femoral  artery  and  vein  of  animals  are  sutured  together  in  a  reversed 
direction  there  is  no  real  reversal  of  the  circulation,  and  the  arterial  blood  never 
goes  more  than  a  short  distance  below  the  knee  and  is  then  quickly  switched 
hack  to  the  iliac  veins  through  the  dilated  collateral  vessels.  Evidently  what 
happened  in  Carrel's  experiments  was  that  dissection  paralyzed  the  vaso- 
constrictor nerves,   and  the   dilated   capillaries  permitted  red   arterial  blood 


'Carrel,   Alexis,   and   Guthrie,    G.    C:    Ann.    Surg.,    1906,    xliii,    203-213. 

=Horsley,  J.  S.,  and  Whitehead,  R.  H. :  A  study  of  Reversal  of  the  Circulation  in  the  Lower  Ex- 
tremity,  J'our.   Am.   Med.   Assn.,    March    13,    1915,   Ixiv,    873-877. 

Horslev,  J.  S.:  Reversal  of  the  Circulation  of  the  Lower  Extremity,  Ann.  Surg.,  March,  1916,  Ixiii, 
277-279. 


GENERAL    CONSIDERATIONS  31 

to  i\o\y  tlirougli  luiclunio'ed.  AVhen  llio  sciatic  and  crural  nerves  are 
divided  in  a  dog',  red  Llood  appears  in  the  femoral  vein  l)ecause  of  the  ex- 
treme dilatation  of  the  capillaries.  Clinically  this  is  often  seen  to  follow 
an  application  of  the  elastic  tourniquet  which,  if  left  on  for  even  a  short  time 
and  tlien  removed,  produces  an  intense  flushing  of  the  limb  until  the  tempora- 
rily i^aralyzed  vasoconstrictors  have  resumed  their  function.  Many  useless 
operations  have  been  done  attempting  so-called  reversal  of  the  circulation 
in  threatened  gangrene.  The  only  good  accomplished  was  damming  back  the 
Aenous  blood  and  forcing  the  small  amount  of  arterial  blood  that  reached 
the  tissues  to  stay  longer  than  it  normally  would,  and  so  deliver  to  the  tissues 
more  nutrition  than  would  be  possible  when  the  arterial  blood  was  quickly 
drained  ot¥  by  unobstructed  veins.  This  can  be  very  simply  effected  by  ligat- 
iiig  the  femoral  vein. 

Surgery  of  the  gastrointestinal  tract  suffers  from  the  lack  of  appli- 
cation of  physiologic  principles.  Take,  for  example,  the  popular  operation 
of  gastroenterostomy.  It  does  relieve  the  symptoms  of  many  patients  with 
duodenal  or  gastric  ulcer.  Many,  however,  still  have  their  symptoms,  and 
restoration  of  the  normal  channels  by  undoing  a  gastroenterostomy  is  an 
operation  not  infrequently  performed.  The  cases  that  are  cured  by  gastro- 
enterostomy have  never  been  fully  explained.  Some  say  it  is  a  drainage 
operation,  and  yet  in  draining  other  hollow  viscera  we  do  not  open  at  the 
lowest  point.  We  drain  the  gall  bladder  and  the  urinary  bladder  from  the 
part  opposite  the  most  dependent  portion,  and  we  do  an  enterostomy  in  the 
distended  loop  of  bowel  that  is  nearest  the  incision,  because  we  know  that 
normal  contraction  or  peristalsis  will  keep  the  bladder  or  bowel  empty  if  an 
opening  is  made.  By  some  it  is  claimed  that  gastroenterostomy  cures  because 
the  acidity  of  the  gastric  juice  is  lessened,  and  still  others  assert  that  by  short 
circuiting  the  course  of  food,  rest  is  given  the  ulcer ;  yet  roentgenoscopy  reveals 
that  unless  the  pylorus  is  closed  a  considerable  portion  of  food  continues  to 
go  by  this  route,  and  no  pyloric  closure  seems  to  be  permanent  unless  a  re- 
section is  made. 

Recent  physiologic  research  by  Cannon  and  Washburn,^  which  has  been 
confirmed  by  Carlson*  and  others,  has  demonstrated  that  the  hunger  pains,  or 
so-called  pangs  of  hunger,  m  a  normal  stomach  are  due  to  excessive  peristaltic 
contractions  of  the  stomach.  It  has  also  been  shoAvn  that  the  pains  that  come 
on  with  clocklike  regularity  after  meals  in  duodenal  or  gastric  ulcer,  are  not 
produced  by  acid  erosion  of  the  ulcer  by  the  hyperacid  gastric  juice,  as  was 
formerly  taught,  but  are  due  to  the  contraction  of  peristalsis  on  gastric  nerves 
made  sensitive  by  the  inflammation  of  the  ulcer.  The  character  of  the  gastric 
juice  has  nothing  to  do  with  the  pain  except  so  far  as  it  excites  an  abnormal 
amount  of  peristalsis.  Food  or  sodium  bicarbonate  lessens  peristalsis  for  a  while 
and  so  relieves  pain.    Investigation  seems  to  show  that  the  stomach  has  a  limited 


'Cannon   and   Washburn:      An    Explanation   of  Hunger,    Am.    Jour.    Physiol.,    1912,    x-xix,   441. 
^Carlson,  A.  J.:     The  Control   of   Hunger  in  Health   and    Disease,   University   of    Chicago   Press,    1916, 
pp.   62-83. 


32  OPERATIVE    SURGERY 

supply  of  nerves  that  conduct  pain,^  and  these  nerves,  which  are  deep  in  the 
stomach  wall,  are  made  more  sensitive  than  normal  by  the  inflammation  around 
an  ulcer.  Consequently,  they  register  impulses  of  pain  from  the  pressure  of 
peristalsis  that  in  a  normal  physiologic  condition  they  would  not  register.  It 
is  probable  that  gastroenterostomy  relieves  pain  by  facilitating  the  emptying 
of  the  stomach  and  so  lessening  peristalsis.  This,  however,  is  largely  the 
treatment  of  a  symptom  and  not  an  effort  to  remove  a  pathologic  condition 
and  to  restore  tissues  to  their  physiologic  state. 

In  the  surgery  of  the  intestine,  the  work  of  Cannon  and  Murphy  in  their 
studies  of  peristalsis  after  resection  of  the  bowel  has  not  received  proper  at- 
tention. Lateral  anastomosis  is  still  the  method  employed  by  many  surgeons, 
though,  as  shown  by  Cannon  and  Murphy,  peristalsis  is  practically  abolished 
in  the  region  of  such  an  anastomosis.  Food  can  be  pushed  through  only  when 
a  column  of  it  extends  into  a  proximal  (oral)  loop  where  peristalsis  is  unim- 
paired. Postmortems  in  dogs  with  lateral  anastomosis  showed  that  there  was 
always  an  accumulation  of  food  at  the  site  of  the  lateral  anastomosis  even 
when  the  rest  of  the  intestinal  tract  was  free,  because  severing  the  circular 
fibers,  in  this  operation,  abolished  peristalsis,  and  the  blind  pouches  could 
not  be  completely  emptied.  They  found  that  in  an  end-to-end  union  there 
was  not  the  slightest  stasis  of  intestinal  contents  at  the  site  of  operation. 
Merely  because  the  lateral  union  usually  gives  no  disagreeable  symptoms,  its 
use  has  been  continued.  If  the  patient  did  not  die  it  was  assumed  that  he 
had  sufficiently  recovered.  With  attention  to  the  triangular  mesenteric  spaces 
and  careful  closure  of  these  and  of  other  raw  surfaces  before  the  bowel  is 
opened,  together  with  disinfection  of  the  bowel  ends  after  opening,  as  good 
technical  results  are  obtained  in  end-to-end  union  as  after  the  lateral  method, 
with  the  advantage  of  securing  normal  peristalsis  and  normal  emptying. 

There  are  many  problems  in  neurologic  surgery  that  require  some  knowl- 
edge of  physiologic  principles  in  order  to  be  settled  satisfactorily.  Spiller 
and  Frazier  have  demonstrated  that  section  of  the  posterior  sensory  root  of 
the  gasserian  ganglion  produces  what  is  called  ''physiologic  extirpation"  of 
the  gasserian  ganglion.  It  has  been  known  for  years  that  a  nerve  which  is 
injured  on  the  central  side  of  its  ganglionic  cells  does  not  regenerate;  yet 
when  the  operation  of  division  of  the  posterior  sensory  root  for  tic  doulou- 
reux was  suggested,  it  was  received  with  some  skepticism.  This  operation  is 
safer  than  surgical  extirpation  of  the  gasserian  ganglion,  and  is  followed  by 
less  trophic  disturbance.  The  plugging  of  foramina  in  the  skull  from  which 
neuralgic  sensory  nerves  have  been  removed  in  order  to  prevent  regrowth  of 
the  nerves,  has  sometimes  been  done  with  metal  screws.  Because  an  iron  screw 
can  stop  a  hole  in  a  piece  of  wood  is  not  necessarily  a  reason  why  it  should 
be  employed  in  living  tissue.  On  the  other  hand,  some  substance  that  does 
not  cause  reaction  in  bone  is  preferable.  What  happens  after  an  iron  screw 
is  applied?     Nature  in  an  effort  to  extrude  the  irritating  substance  removes 

'  sic^st  and  Meltzer:     Med.   Rec,   New   York,   Ixx,   1017;   Rittcr :   Zentralbl.    f.   Chin,    1908,   xxxiv,   609. 

Langley:     Brain,   1903,  xxvi,  23. 


GENERAL    CONSIDERATIONS  33 

liiiu>  salts  ill  ils  ii(M<i'lil)()i-li(io(l,  llic  lioiio  softens,  tiic  screw  ])ee()iiies  loose,  and 
the  iier\e  can  i^row  aroiind  it. 

Tlie  liistoiy  of  sui'^cry  of  liydroeoplialiis  contains  many  illustrations  of 
the  iiei^lect  of  the  appreciation  of  hiologic  principles  in  surg'ieal  operations. 
Various  operations  for  this  disease  have  been  based  upon  an  effort  to  secure 
drainage  from  the  ventricles  of  the  brain  into  the  tissues  of  the  neck  with  the 
idea  that  the  excessive  cerebrospinal  fluid  would  be  absorbed  from  this  region. 
Tubes  and  threads  of  various  kinds  have  been  run  from  the  lateral  ventricle 
through  the  skull  and  into  the  tissues  of  the  neck  or  scaljo.  There  seems  to  have 
been  very  little  consideration  of  how  the  absorption  would  take  place  after  the 
mechanical  features  of  the  operation  had  been  completed.  It  is  obvious  that 
a  continuous  injection  of  even  a  nonirritating  fluid,  such  as  salt  solution, 
beneath  the  skin,  produces  after  the  course  of  a  few  days,  an  exudate  which, 
to  a  large  extent,  blocks  the  Ij^mphatics  and  greatly  retards  absorption.  AVhen 
this  takes  place,  it  is  only  possible  to  cause  the  fluid  to  be  absorbed  by  greatly 
increasing  the  pressure.  Such  pressure,  if  produced  in  the  brain,  Avould  be 
fatal  from  compression  of  the  brain.  Consequently,  even  if  the  cerebrospinal 
fluid  could  flow  unobstructed  from  the  ventricles  of  the  brain  through  a  tube 
or  along  threads  into  the  neck,  the  intracerebral  pressure  necessary  to  force  ab- 
sorption would  soon  be  so  great  as  to  impair  the  function  of  the  brain.  The  rea- 
son that  such  operations  are  sometimes  successful  is  because  the}'  do  not  drain 
as  they  are  supposed  to  do,  but  incidentally  provide  for  the  increased  pres- 
sure of  fluid  within  the  brain  b}^  the  removal  of  a  portion  of  the  skull  which 
is  necessary  for  the  operation..  Such  instances  of  permanent  improvement, 
however,  are  fe^v  and  far  between. 

The  fashion  for  plating  fractures  fortunately  is  on  the  decline.  Hun- 
dreds and  probably  thousands  of  fractures  have  been  plated  with  heavy 
metal  plates  for  no  reason  except  that  it  appeals  to  the  mechanical  sense  and 
because  some  eminent  surgeons  advocated  this  operation.  In  many  cases  it 
is  followed  by  attempted  extrusion  of  the  plate  wdiich  later  has  to  be  removed. 
To  the  casual  observer  it  seems  strange  that  permanent  union  does  not  always 
occur  when  a  nice  cabinet  joint  is  made  between  the  ends  of  a  fractured  bone 
and  the  ends  are  held  securely  in  position  by  steel  plates  and  screws.  The 
same  process  goes  on  here  as  when  an  effort  is  made  to  plug  a  foramen  in  the 
bone  with  iron.  The  iron  is  an  irritating  foreign  substance,  and  in  order  to 
extrude  it,  nature  causes  an  absorption  of  the  lime  salts.  As  a  result,  a  screws 
which  may  at  first  be  firmly  fixed  in  the  bone  soon  becomes  loose ;  but  more 
important  is  the  fact  that  osteoporosis  is  induced  in  this  effort  at  extrusion, 
and  callus  formation  is  thereby  prevented  or  retarded.  A  poorly  fixed  frac- 
ture without  the  use  of  metal  is  more  likely  to  give  eventual  good  results  than 
the  neatest  union  by  heavy  plates  and  screws. 

That  emotions  have  considerable  bearing  on  the  prognosis  in  certain 
cases  of  surgery  has  long  been  accepted.     Cannon,"  has  demonstrated  that 


f^Cannon,   W.   B.:      Bodily    Ch?-§es    in    Pain,   Hunger,    Fear   and    Rage,    New   York,    1915,    D.    Appleton 
&  Co.,  pp.  52-80. 


34  OPERATIVE    SURGERY 

fright  or  profound  anxiety  causes  a  stimulation  first  of  the  sympathetics  and 
then  of  the  suprarenals.  The  aetion  of  epinephrin  amounts  to  a  prolonged 
stimulation  of  the  sympathetic  nervous  system.  Thus  the  body  is  put  on  Avhat 
may  be  called  a  war  basis,  the  circulation  is  more  active,  the  heart  beats  faster, 
the  pupils  are  dilated,  respiration  is  accelerated,  and  metabolism  generally  is 
increased.  Often  there  is  so  much  glycogen  released  from  the  liver  as  to 
cause  marked  glycosuria,  especially  if  the  body  is  at  rest ;  but  if  the  emotions 
are  accompanied  by  physical  action,  as  fighting  or  running,  this  excessive 
amount  of  sugar  may  be  consumed.  The  moral  is  that  in  some  surgical  cases 
it  undoubtedly  makes  the  prognosis  better  if  emotions  of  fear  or  anxiety  are 
alla^'ed  as  much  as  possible.  In  diseases  such  as  exophthalmic  goiter,  meas- 
ures that  abolish  or  diminish  fear  or  excitement  are  of  the  greatest  impor- 
tance, and  an  operation  should  be  so  selected  and  performed  as  to  carry 
out  these  indications. 

Skin  grafting  and  transplantation  of  organs  or  tissues  are  dependent  on 
biologic  laws.  Surgeons  who  have  had  great  experience  in  this  type  of  work, 
such  as  Lexer,"  and  Davis,  believe  that  skin  grafts  from  others  than  the  pa- 
tient are  practically  never  permanent.  They  either  melt  away  at  once,  or  if 
they  appear  to  "take"  are  later  absorbed  and  replaced  by  connective  tissue. 
It  has  been  suggested  that  tests,  as  for  transfusion  of  blood,  Avould  be  of  bene- 
fit in  selecting  a  donor  for  skin  grafting;  but  so  far  this  has  not  been  put  to 
any  extensive  practice.  The  transplantation  of  highh-  developed  organs,  such 
as  a  kidney,  from  one  animal  to  another,  even  of  the  same  species,  is  always  a 
failure.  The  kidney  may  functionate  for  a  while,  but  the  fine  biologic  dif- 
ferences in  the  body  fluids  of  the  donor  and  the  recipient  cause  degeneration, 
and  the  kidney  eventually  becomes  a  mass  of  connective  tissue.  This  has  been 
acknowledged  by  Carrel,  Guthrie  and  others  who  were  at  one  time  enthusiastic 
about  the  success  of  such  a  procedure.  The  reconstruction  of  channels,  as  the 
bile  ducts,  from  tissues  that  have  no  immunity  to  the  irritating  discharges 
with  which  they  must  come  in  contact  is  also  unwise.  Operations  in  which 
strips  of  fascia,  pieces  of  vein*  and  other  tissue  unaccustomed  to  the  action  of 
bile  are  used,  ultimately  result  in  failure,  no  matter  how  skillfully  the  mechan- 
ical part  of  the  operation  is  done. 

These  are  merely  a  fcAV  instances  of  what  every  sUrgeon  sees  in  his  work, 
and  they  illustrate  the  profound  influence  that  the  application  of  biologic 
principles  has  on  surgical  practice.  Real  progress  in  surgery  lies  not  so  much 
in  cultivating  the  art  of  surgerj"  and  in  striving  after  mechanical  dexterity, 
which  is  important  but  can  be  acquired  in  a  few  years,  as  in  the  study  of 
biologic  principles  that  concern  function,  nutrition,  metabolism,  and  repair  of 
tissues,  and  in  the  thoughtful  application  of  these  principles  to  every  operation 
and  to  every  method  of  surgical  treatment. 


'Lexer,    E. :    Ann.    Surg.,    1914,    Ix,    172-174. 

■'"Horslev,  J.   S.:      Reconstruction   of  the  Common   Tlile   Duct,  Jour.   Am.   Med.   Assn.,   October   12,   1918, 
Ixxl,    1188-1194. 


CHAPTER  II 
SURGICAL  DRAINAGE* 

The  biologic  defenses  of  the  body  against  disease,  trauma  and  the  wear  of 
age  are  wonderful,  but  they  are  not  perfect.  If  they  were  perfect,  man  would 
live  forever.  Particularly  interesting  is  the  manner  in  which  the  body  protects 
itself  against  injurious  foreign  substances.  The  epithelial  lined  body  cavities 
have  more  or  less  specialized  methods  of  protection.  The  stomach,  for  instance, 
b}'  vomiting,  emits  food  that  is  spoiled,  and  many  drugs  that  are  irritating  or 
disagreeable  to  the  taste,  and  sometimes  even  rejects  substances  that  are  thought 
to  be  nauseating  or  obnoxious  even  though  they  are  not.  The  excessive  salivation 
when  nausea  occurs  probably  tends  to  dilute  the  offensive  material,  or  to  protect 
the  walls  of  the  mucous  membrane.  Vomiting  undoubtedly  is  a  habit  that  was 
acquired  in  the  early  days  of  evolution.  The  more  refined  drugs  or  poisons 
that  are  a  result  of  chemical  manufacture  have  not  created  a  similar  defense  by 
the  stomach,  and  are  often  retained. 

Foreign  irritating  substances  in  the  rectum,  the  bladder  or  the  larynx 
are  also  expelled  by  muscular  action.  Irritating  matter  in  the  nose  causes  a 
profuse  secretion,  which  tends  to  wash  away  the  offending  substance.  An  irri- 
tating foreign  body  in  the  eye  causes  at  once  a  flow  of  tears  in  an  effort  to  wash 
it  away,  and  at  the  same  time  the  spasm  of  the  muscle  of  the  eyelids  is  probably 
due  partly  to  an  effort  to  expel  the  foreign  body,  as  well  as  to  protect  against 
further  injury. 

In  endothelial  lined  cavities  or  in  solid  tissue  there  is  an  attempt  to  wash 
away  foreign  irritating  matter.  This  is  done  by  the  pouring  out  of  serum  from 
the  lymph  circulation  in  the  neighborhood  of  the  foreign  substance,  which  is 
accomplished  by  the  reversal  of  the  circulation  in  the  local  lymphatics,  so  as  to 
empty  their  contents  around  the  irritating  material.  This  is  really  the  chief 
basis  of  surgical  drainage. 

In  surgical  drainage,  mechanical  measures  that  are  followed  by  fortunate 
results  would  appear  ridiculous  if  no  biologic  conditions  existed.  In  preventing 
infection  of  a  fresh  raw  surface,  or  in  the  so-called  walling  off  of  healthy  tissue 
from  the  products  of  infection,  gauze  is  often  placed  over  the  raw  surface  or 
as  a  coffer-dam  in  the  abdominal  cavity,  and  an  abscess  is  drained  through  the 
center  of  this  gauze  packing.  If  we  could  convert  this  into  a  mechanical  propo- 
sition and  imagine  that  the  pus  was  a  solution  of  methylene  blue  and  that  it 
was  flowing  over  this  raw  surface  which  had  been  covered  with  absorbent  gauze 
to  prevent  contamination,  we  know  that  both  the  gauze  and  the  wound  would 
be  deeply  stained.    This  method  of  protection,  however,  does  act  in  a  beneficial 


*This   chapter   is   largely   a  reproduction   of   a  previously   published   paper:     Horsley,    J.    S. :      Surgical 
Drainage  from  a  Biologic  Point  of  View,  Jour.  Am.  Med.  Assn.,  Jan.   17,   1920,   Ixxiv,   159-162. 

35 


36  OPERATIVE    SURGERY 

manner,  and  a  clean  wonnd  is  often  l)y  this  means  kept  from  septic  infection. 
The  drainage  of  a  peritoneal  abscess  is  practical!}^  always  np-hill  and  is  usually 
successful.  If  mechanics  were  the  only  principle,  how  could  an  appendiceal 
abscess  ever  be  drained  by  putting  a  tube  down  to  it  through  the  abdominal 
incision?  The  whole  method  of  drainage  really  depends  on  the  reversal  of 
the  circulation  in  the  local  lymphatics  and  is  chiefly  a  biologic  process.  It  is 
nature's  effort  to  extrude  a  foreign  substance. 

A  splinter  in  the  finger  which  becomes  mildly  infected  will  provoke  a  dis- 
charge of  thin  seropus  for  days.  This  is  nature's  effort  to  expel  the  splinter.  Af- 
ter it  has  been  removed,  the  wound  rapidly  closes;  and  the  lymph  circulation, 
which  was  in  part  at  least  reversed  in  an  effort  to  extrude  the  splinter,  assumes 
its  normal  course,  and  probably  in  tv\'enty-four  hours  after  the  splinter  has  been 
removed  there  is  no  further  discharge. 

The  peritoneum  and  its  underlying  structures  in  the  abdominal  cavity 
constitute  an  enormous  lymph  space,  and  the  lymph  is  here  abundantly  poured 
out  in  response  to  an  irritation.  The  insertion  of  a  drainage  tube  causes  a 
reaction  in  which  there  is  a  flow  of  lymph  in  an  effort  to  expel  the  drainage 
tube.  Drainage  of  the  abdominal  cavity  prevents  j)ositive  pressure  in  the  septic 
region,  and  also  the  drainage  tube  is  a  stimulus  for  a  reversal  of  the  lymphatic 
circulation.  The  packing  of  a  fresh  wound  with  gauze  causes  a  similar  reversal 
of  the  lymphatic  circulation ;  and  though  pus  may  flow  over  this  gauze  from  a 
deeper  focus,  the  lymx)hatics,  instead  of  absorbing  the  pus,  pour  out  lymph 
into  and  around  the  gauze  to  extrude  it.  The  beneficial  action  of  the  cigarette 
drain,  which  is  soon  clogged  with  coagulated  lymph,  is  comprehensible  when  we 
look  on  it  as  a  stimulus  for  reversal  of  the  local  lymphatic  circulation. 

In  regions  of  the  body  in  which  the  lymj)h  supply  is  less  abundant  than  it 
is  in  the  abdomen,  unless  the  infected  focus  is  very  small,  it  will  be  necessary  to 
utilize  gravity  when  instituting  drainage,  because  there  is  not  a  sufficient  flow 
of  lymph  to  flush  the  septic  cavity  thoroughly  and  constantly,  as  there  is 
with  abdominal  drainage. 

Drainage   in   surgical   operations   may   be    classifled   under    three    heads: 

CLASSIFICATION  OF  SURGICAL  DRAINAGE 

1.  Drainage  of  solid  tissue  or  endothelial  lined  cavities: 

(a)  Drainage  of  endothelial  covered  tissues  of  the  abdominal  cavity. 

(b)  Drainage  of  other  endothelial  lined  cavities,  as  pleura,  joints. 

(c)  Drainage  of  solid  soft  tissue,  as  muscle,  fascia,  fat. 

(d)  Drainage  of  bone. 

2.  Drainage  of  inflammatory  products  from  infected  epithelial  lined  hol- 
low viscera,  as  the  gall  bladder  and  the  urinary  bladder. 

3.  Drainage  of  hollow  viscera  in  order  to  restore  function  or  to  secure 
physiologic  rest. 


surgical  drainage  37 

1.  Drainage  of  Solid  Tissue  or  Endothellvl  Lined  Cavities 

Consideriiio'  first  (1-a),  drainage  of  ai)dominal  abscesses,  we  find,  as  has 
already  been  stated,  that  the  abdomen  has  an  enormous  supply  of  lymph  and 
that  the  sueeessfnl  drainage  of  an  abscess  in  this  region  consists,  first,  of  re- 
lieving the  pressure  in  the  abscess  cavity  by  opening  it  and  inserting  a  drain ; 
and,  second,  of  inducing  a  sufficient  reversal  of  the  lymph  circulation  by  the 
presence  of  the  drainage  material  to  cause  much  of  the  septic  products  to  be 
washed  away  along  the  drainage  track.  If  the  drainage  material  reaches  the 
abscess  cavity  so  that  the  pus  is  not  under  positive  pressure,  and  if  the  drainage 
is  sufficient  in  amount  and  of  the  proper  kind  to  act  as  a  stimulus  for  reversal 
of  the  lymphatic  circulation,  so  much  lymj^h  is  poured  out  that  practicalh^  a 
continuous  irrigation  is  going  on  from  the  local  lymphatics  along  the  tube  or 
track  of  the  drainage  material,  and  it  is  a  matter  of  but  little  importance  whether 
the  drainage  material  is  pointed  up  or  down.  But  in  other  endothelial  cavities 
(1-b),  such  as  the  pleura  or  the  joints,  where  the  lymphatic  supply  is  much 
smaller  than  in  the  abdomen  or  where  the  configuration  is  such  as  to  make  the 
drainage  difficult,  gravity  must  aid  and  the  problem  becomes  more  mechanical 
than  biologic.    Drainage  here  should  be  at  the  lowest  point  possible. 

Drainage  carried  down  to  sutured  bowel  frequently  results  in  a  fistula, 
particularly  if  gauze  in  the  form  of  a  cigaret  drain  is  employed.  The  reversal 
of  the  lymphatic  circulation  in  the  neighborhood  of  a  recently  sutured  intestinal 
wound,  which  will  direct  the  current  of  lymph  to  the  drainage,  interferes  with 
the  normal  process  of  repair  in  the  intestinal  wound,  causes  a  weak  fibrinous 
deposit,  and  diminishes  the  nutrition  of  the  repairing  bowel;  consequently,  the 
sutures  readily  break  down  and  a  fistula  results. 

In  drainage  of  muscles,  fascia  and  fat  (1-c),  gravity  drainage  must  be 
considered,  but  the  biologic  problem  is  also  prominent.  An  abscess  in  the 
thigh  heals  better  if  gravity  drainage  is  instituted.  The  drainage  material 
should  be  sufficient  not  only  to  carry  off  the  secretion  but  also  to  excite  the 
local  lymphatics  to  reverse  their  circulation.  The  local  lymphatics,  being  much 
less  abundant  than  in  the  abdomen,  cannot  usually  furnish  enough  lymph  to 
cause  the  flushing  out  of  the  septic  products,  as  occurs  in  the  abdomen.  In 
rapidly  spreading  inflammation,  wide  incisions  and  drainage  are  useful  in 
relieving  the  pressure  that  is  made  by  the  binding  fascia  or  skin,  and  in  re- 
versing the  circulation  of  the  lymphatics  and  so  preventing  absorption  of  much 
of  the  septic  products  into  the  main  lymphatic  trunks. 

The  old  operation  of  "fence  rail"  incisions  along  the  margin  of  an  ad- 
vancing erysipelas  causes  the  pouring  out  of  lymph  from  these  cuts  and  the 
diversion  of  the  lymph  current,  which  would  otherwise  carry  the  septic  prod- 
ucts to  further  uninfected  regions.  The  undermining  of  the  skin  and  insertion 
of  tubes  or  gauze  drainage  from  point  to  point  make  the  pouring  out  of  lymph 
along  the  drainage  material  even  greater  than  after  a  simple  incision. 

That  the  reversal  of  the  circulation  is  the  chief  biologic  process  by  which 
surgical  drainage  acts  beneficially  in  solid  soft  tissue,  can  also  be  recognized 
when  there  is  a  small  abscess  in  a  large  amount  of  inflammatory  exudate  and  it 


38  OPERATIVE   SURGERY 

is  impossible  to  locate  the  small  abscess  cavit}-.  If  a  drain  is  placed  in  its 
immediate  neighborhood  the  abscess  frequently  opens  into  the  drain.  It 
seems  probable  that  this  occurs  because  the  lymphatic  current  attempts  to  ex- 
trude the  drain  and  so  the  products  of  the  abscess  are  carried  in  this  direction, 
and  the  abscess  burrows  to  the  tube. 

The  drainage  of  tissues  whose  lymphatic  trunks  have  been  clogged  and 
where,  consequently,  edema  is  present  depends  on  an  effort  to  increase  the 
lymphatic  circulation  or  to  create  new  lymphatic  connections.  In  the  operation 
of  Handley  in  which  long-  threads  of  silk  are  placed  under  the  skin  in  edema 
of  the  arm,  lymphatic  channels  form  along  the  threads.  In  the  operation  of 
Kondoleon,  the  deep  fascia  of  the  arm  or  leg  is  split  in  order  to  promote  an 
anastomosis  between  the  deep  and  the  superficial  sets  of  lymphatics  and  so  to 
divert  the  lymph  current  from  the  superficial  to  the  deep  lymphatic  trunks. 

Local  edemas  that  are  persistent  are  usually  caused  by  blockage  of  the 
lymphatic  channels  and  not  by  interference  with  the  blood  circulation.  The 
edema  that  sometimes  appears  in  the  arm  after  a  radical  operation  for  cancer 
of  the  breast  in  which  the  axilla  is  thoroughly  dissected  is  due  to  the  removal 
of  the  lymphatics.  If  this  immediately  follows  operation,  it  may  disappear 
when  the  collateral  lymphatic  circulation  is  established;  but  when  a  late  edema 
results  it  is  frequently  because  the  lymphatics  have  become  plugged  with  cancer 
cells;  and  such  an  edema  is  ominous.  Resection  of  the  axillary  vein  if  the 
lymphatics  are  in  satisfactory  condition,  is  followed  by  but  little  if  any  swelling 
in  the  arm,  and  that  of  a  temporary  nature.  A  phlebitis  causes  edema  only 
when  the  lymphatics  around  the  vein  are  involved  in  the  inflammation. 

Drainage  of  wounds  after  radical  operations  for  carcinoma  in  solid  tissue 
should  alwaj^s  be  done.  This  is  not  so  much  in  order  to  carry  off  the  fluids  that 
may  accumulate  in  the  wound,  as  an  effort  to  reverse  the  circulation  of  the 
lymphatics  which  may  be  induced  to  pour  out  their  contents  in  the  direction 
of  the  drainage  tube  and  so  to  discharge  through  this  drainage  cancer  cells  that 
have  been  left  in  the  wound  or  that  may  have  lodged  in  the  open  lymphatics. 
This  is  an  important  step  in  many  radical  operations  for  cancer,  as  after  opera- 
tions in  the  neck  or  on  the  mammary  gland. 

Drainage  of  bone  (1-d)  involves  problems  of  a  somewhat  different  nature, 
because  of  the  structure  of  bone.  Bone  is  compact,  rigid  tissue  in  which  lime 
salts  are  arranged  in  an  orderly  way.  On  account  of  the  rigid  structure  it  is 
impossible  for  either  blood  vessels  or  lymphatics  to  form,  or  for  the 
lymph  current  to  reverse,  as  readily  as  in  soft  tissue.  Before  drainage  can  be 
accomplished  or  any  effective  stand  against  infection  can  be  made,  the  lime 
salts  must  be  removed,  so  converting  bone  into  what  is  practically  soft  tissue. 
For  this  reason,  in  areas  of  inflammation  bone  is  always  soft.  Around  an  irri- 
tating substance  in  bone,  whether  accompanied  by  infection  or  not,  lime  salts 
are  absorbed.  When  this  is  accomplished  the  offending  material  becomes  loose 
and  is  prepared  for  extrusion.  If,  for  instance,  a  piece  of  iron,  as  a  screw  used 
in  plating  bone,  is  inserted  into  a  bone,  the  lime  salts  in  the  neighborhood  of 
the  screw  and  of  the  plate  are  absorbed.    The  screws,  which  may  have  been  very 


SURGICAL    DRAINAGE  39 

ti^lit  and  firm  when  inserted,  gradually  become  loose.  This  induced  osteopo- 
rosis around  the  screws  and  the  metal  plate  is  just  the  reverse  of  what  is  desired 
when  a  fractnre  is  to  be  repaired,  and  it  accounts  for  the  frequency  of  nonunion 
after  the  plating  of  bones. 

The  numerous  so-called  abscesses  at  the  roots  of  teeth  are  probably  often 
the  result  of  the  reaction  of  the  bone  in  the  neighborhood  to  some  material  that 
was  used  in  filling  the  cavities  in  the  roots  of  the  teeth.  Undoubtedly  apical 
abscesses  frequently  occur,  but  it  is  probably  equally  true  that  an  osteoporosis 
sometimes  interpreted  as  an  apical  abscess  may  be  sterile  and  due  to  the  re- 
action of  the  bone  to  the  material  with  which  the  root  of  the  tooth  has  been 
filled. 

Because  of  the  poor  lymphatic  supply  of  bone  and  its  rigid  walls  which 
protect  its  vessels,  a  bone  abscess  may  be  more  readily  disinfected  by  means  of 
strong  antiseptics,  such  as  phenol  (carbolic  acid),  than  if  the  abscess  were  in 
soft  tissue.  Here,  as  disinfection  can  be  more  thorough,  the  necessity  for  full 
drainage  in  the  milder  chronic  infections  of  the  bone  is  not  so  great,  if  the 
diseased  bone  has  been  removed,  as  it  would  be  in  soft  tissue.  Consequently, 
''fillings"  or  "bone  plugs"  are  utilized. 

2.  Drainage  of  Inflammatory  Products  From  Infected  Epithelial 

Lined  Hollow  Viscera,  As  the  Gall  Bladder  or  the 

Urinary  Bladder 

-Drainage  here  involves  principles  different  from  the  drainage  of  an  ab- 
scess that  has  formed  in  solid  tissue.  This  drainage  not  only  is  for  removing 
the  products  of  infection,  but  serves  a  double  purpose  of  also  giving  physio- 
logic rest  to  the  infected  organ.  The  drainage  of  a  septic  gall  bladder  that 
may  be  filled  with  pus  carries  off  the  products  of  the  bacteria  and  at  the  same 
time  gives  rest  to  the  gall  bladder  by  preventing  distention,  and  this  removes 
both  a  stimulus  for  contraction  and  the  tension  that  would  occur  on  the  dis- 
tended walls.  Drainage  of  this  type  does  not  have  to  be  gravity  drainage.  If 
a  sufficient  opening  is  provided  in  the  general  axis  of  the  peristaltic  current, 
it  is  all  that  is  necessary.  In  draining  an  infected  urinary  bladder,  for  instance, 
an  opening  made  at  the  top  of  the  bladder  is  as  satisfactory  in  securing  results 
as  an  opening  at  the  bottom. 

When  these  hollow  muscular  organs  are  contracted,  a  small  opening 
will  insure  the  vicera  keeping  empty  if  it  is  made  in  due  regard  to  the  action 
of  peristalsis.  Even  in  such  instances,  however,  the  beneficial  action  of  the 
drainage  is  not  solely  the  removal  of  the  contents  of  the  hollow  viscera  or  the 
giving  of  physiologic  rest.  It  seems  highly  probable  that  reversal  of  the 
lymphatic  current  is  also  of  importance  here.  This  appears  to  be  borne  out 
by  the  results  of  drainage  of  the  bile  tracts  in  inflammation  of  the  pancreas. 
It  is  well  known  that  chronic  pancreatitis  can  best  be  treated  by  prolonged 
drainage  of  the  bile  tracts;  and  drainage  of  the  common  bile  duct  for  this 
affection  seems  to  be  particularly  effective.     The  work  of  Deaver  and  Pfeif- 


40  OPERATIVE    SURGERY 

fer^  on  pancreatic  and  peripancreatic  lymphangitis  is  interesting  in  this 
connection.  They  call  attention  to  the  anatomy  of  the  lymphatic  supply  of 
of  the  pancreas  and  its  ultimate  connection  with  the  lymphatic  supply  of  the 
bile  tracts  and  gall  bladder.     They  say: 

''To  the  objection  that  infection  to  be  carried  into  the  pancreas  must 
stem  the  efferent  lymph  current  and  force  the  valves,  the  answer  can  be 
made  that  everyone  has  seen  infection  in  cellular  tissues  proceed  in  a  re- 
verse direction  to  the  lymph  current.  Thrombolymphangitis  readily  di- 
verts the  normal  lymph  course  and  infection  easily  destroys  valves.  The 
forces  of  pathology  here  as  in  so  many  other  instances  pervert  the  normal 
function." 

If  infection  of  the  pancreas  can  be  through  the  lymphatic  supply  from 
the  gall  bladder  or  the  gall  tracts,  as  Deaver  and  Pfeiffer  assert,  it  seems  that 
the  method  of  relieving  this  infection  is  to  reverse  the  Ijanphatic  current 
and  cause  it  to  be  diverted  toward  the  drainage  tube  and  the  incision  in  the 
gall  bladder  or  in  the  common  duct,  just  as  the  lymph  flow  is  reversed  in  the 
drainage  of  an  abdominal  abscess.  Septic  products  that  would  be  carried  in 
the  lymphatics  from  the  infected  gall  bladder  to  the  pancreas  are  thus  di- 
verted to  the  drainage  tube  in  an  effort  to  extrude  it.  If  this  diversion  can 
be  maintained  sufficiently  long  to  permit  nature  to  build  up  the  resistance  of 
the  pancreas  to  the  infection  and  repair  the  damage  already  done,  the  pa- 
tient may  be  considered  cured.  But  if  the  drainage  tube  is  removed  too 
soon,  there  is  no  further  stimulus  for  a  reversal  of  the  lymph  circulation, 
and  the  pancreatitis  recurs. 

Too  early  resumption  of  function  after  drainage  of  inflamed  hollow 
viscera  frequently  results  in  a  recurrence  of  the  inflammation.  This  may  be 
due  to  one  of  three  causes,  or  more  probably  to  a  combination  of  three 
causes:  (1)  There  may  be  an  accumulation  of  secretion  that  is  not  free  from 
the  products  of  the  inflammatory  process.  (2)  There  is  an  interruption  of 
physiologic  rest.  (3)  There  is  a  change  in  the  lymph  current  from  that  which 
has  been  instituted  by  the  drainage.. 

3.  Drainage  of  Hollow  Viscera  for  Physiologic  Rest 

In  enterostomy,  the  operation  may  be  done  to  side-track  the  normal 
contents  of  the  hollow  viscera  and  so  to  afford  less  Avork  for  the  diseased 
tissue  beloAv  the  point  of  opening,  as  in  colostomy  for  disease  of  the  large 
bowel  farther  down.  Drainage  may  be  instituted  to  prevent  distention  of 
a  hollow  viscus  and  so  induce  rest  in  order  that  an  operative  wound  may 
heal.  This  principle  is  put  into  practice  in  such  operations  on  the  bladder 
as  for  vesicovaginal  fistula  when  a  self-retaining  catheter  is  placed  in  the 
urethra,  and  in  the  introduction  of  a  tube  through  the  rectum  and  through 
the  site  of  resection  of  the  sigmoid  or  left  colon  in  order  to  draw  off  the  gas 
and  prevent   distention   in   the   region   of   the   operation.      This   principle    of 


^Deaver,  J.  E.,  and   Pfeiffer,   D.    B.:     Pancreatic  and    Peripancreatic   Lymphangitis,    Ann.    Surg.,    1913, 
Iviii,   151-163. 


SURGICAL    DRAINAGE  41 

draiiuige   is  often   utilized   after   the   removal   of   stones   from   an   uninfected 
"■all  bladder. 

DRAINAGE  MATERIAL 

Tlie  material  for  drainage  must  be  considered  not  only  with  regard  to 
transporting  the  products  that  are  to  be  drained,  but  also  with  regard  to  the 
biologic  influence  of  the  drain  on  the  local  lymphatics.  Certain  substances 
call  for  a  more  pronounced  flow  of  lymph  than  others.  Rubber,  for  instance, 
is  not  so  irritating  to  tissue  as  gauze.  AVhen  gauze  is  placed  over  a  raw 
surface,  the  local  lymphatics  pour  into  the  gauze  quantities  of  lymph.  This 
is  Nature's  effort  to  extrude  an  irritating  foreign  substance.  When  the  lymph 
has  coagulated,  the  meshes  of  the  gauze  become  entangled  with  the  wound  and 
an  effort  to  remove  the  gauze  before  this  fibrin  has  softened  results  in  tear- 
ing the  delicate  tissues  of  the  wound  and  injures  its  granulations,  causing 
bleeding.  An  ideal  drainage  material  would  be  one  which,  on  the  one  hand, 
is  a  pronounced  stimulus  for  the  lymph  to  be  poured  out  along  the  drain,  and, 
on  the  other  hand,  would  not  be  sufficiently  attached  to  the  raw  surface 
of  the  wound  to  injure  it.     This  material  has  not  yet  been  found. 

Rubber  drainage  tubes  are  frequently  used,  and  have  the  advantage  of 
draining  off  inflammatory  products  readily;  but  they  do  not  provoke  such  an 
outpouring  of  lymph  as  gauze  would.  Naturally,  however,  the  larger  the 
tube  the  greater  the  irritation,  and  the  more  pronounced  the  stimulus  for 
a  reversal  of  the  circulation  of  the  local  lymphatics.  Consequently,  for  drain- 
ing an  abdominal  abscess,  it  is  often  found  that  a  large  tube  does  better  than 
a  smaller  one,  not  because  the  smaller  one  is  insufficient  to  carry  off  the 
serum  or  the  pus,  but  because  the  small  tube  is  not  large  enough  to  provoke  a 
sufficient  amount  of  reaction  among  the  local  lymphatics.  Frequently  the 
advantages  of  both  gauze  and  rubber  are  combined  by  placing  a  gauze  strip 
inside  the  tube  or  by  wrapping  strips  of  gauze  in  rubber  tissue  or  rubber 
dam,  which  is  called  a  ''cigarette  drain,"  and  using  this  in  addition  to  a  tube. 
In  this  way  the  gauze  which  is  exposed  at  the  end  of  the  cigarette  drain  causes 
a  more  pronounced  flow  of  lymph  than  the  rubber  tube  alone  could  produce, 
and  the  tube  drains  away  the  lymph  that  is  thrown  out  to  extrude  the  gauze 
and  the  tube.  Drainage  material  should  not  remain  too  long  in  a  wound, 
else  it  will  act  as  the  infected  splinter  mentioned  above. 

Combinations  that  are  effective  have  been  worked  out  to  a  large  extent 
empirically.  Sometimes  strands  of  catgut,  silkworm-gut,  or  strips  of  rubber 
tissue  are  inserted  into  a  wound  in  which  it  is  anticipated  that  there  may  be 
a  collection  of  serum  or  broken  down  fat  on  account  of  the  nature  of  the 
wound.  This  foreign  substance,  the  drainage  material,  directs  the  current 
of  the  lymphatic  flow  toward  itself  and  so  prevents  an  accumulation  in  the 
tissues  which  might  later  become  a  culture  medium  for  bacteria.  An  open 
superficial  abscess  often  needs  no  drainage  material,  for  the  necrotic  products 
of  the  inflammatory  process  are  a  sufficient  stimulus  for  drainage. 


42  OPERATIVE   SURGERY 

ENCAPSULATED  FOREIGN  BODIES  IN  THE  PERITONEUM 

If  such  foreign  materials  as  gauze  or  cork  are  left  in  the  abdominal  cavity 
under  sterile  conditions,  they  are  rapidly  surrounded  by  a  deposit  of  fibrin, 
as  shown  by  Hertzler.-  This  fibrin,  which  is  coagulated  lymph,  soon  is 
covered  with  endothelium  and  takes  on  the  characteristics  of  peritoneum.  If 
the  gauze  is  left  for  a  number  of  weeks  or  months,  it  may  intrude  into  a 
neighboring  hollow  viscus  and  be  expelled,  as  this  may  be  the  point  of  least 
resistance  and,  consequently,  of  greatest  pressure.  Instances  are  recorded 
in  Avhich  gauze  that  has  been  accidentally  left  after  a  surgical  operation  has 
been  expelled  by  the  bowel  or  by  the  bladder  months  or  years  later.  Some- 
times, however,  the  gauze  is  completely  encapsulated  with  a  cystlike  wall 
and  becomes  so  thoroughly  infiltrated  with  fibrin  that  partial  organization 
takes  place.  Portions  of  the  gauze  may  be  disintegrated  and  removed  by 
phagocytes,  and  the  connective  tissue  penetrating  the  rest  of  the  gauze  is 
so  intimate  that  it  may  have  to  be  dissected  away  with  much  dif^culty. 

CRITICISMS 

The  phrase  ''reversal  of  the  lymph  circulation"  may  not  have  been  happily 
chosen,  but  I  know  no  other  that  would  be  quite  as  satisfactory.  I  fully 
appreciate  the  impossibility  of  any  reversal  of  blood  circulation  and  in  other 
communications  I  have  attempted  to  demonstrate  that  a  vein  and  its  con- 
tributing branches  would  not  function  as  an  artery  when  an  arterial  current 
is  turned  into  the  vein.^  It  was  at  one  time,  however,  rather  generally  held 
that  the  blood  circulation  could  be  reversed  in  this  manner. 

The  phrase  "reversal  of  the  lymph  circulation"  is  not  intended  to  mean 
reversal  in  the  physiologic  sense,  that  is,  change  in  the  direction  of  the 
lymph  current  within  its  normal  channels.  Surgical  drainage  is  not  a  physio- 
logic but  a  pathologic  process.  Lymph  or  serum  is  continually  poured  around 
an  ofifending  foreign  body  until  the  foreign  body  is  removed.  This  lymph 
comes  partly  from  the  injured  lymph  channels  and  lymph  spaces  in  the  tissues 
and  partly  through  the  uninjured  walls  of  the  lymph  channels  which  become 
more  permeable  with  the  hyperemia  that  is  present  when  surgical  drainage 
is  necessary. 

These  are  facts  that  are  largely  self-evident.  The  moot  point  is  whether 
this  process  can  be  called  reversal  of  the  lymph  circulation.  This  phrase 
was  used  because  it  seems  to  me  that  the  current  of  lymph  or  serum  con- 
tinually poured  out  to  the  surface  of  the  skin  for  daj'S  or  weeks  constitutes  in 
a  sense  a  circulation  of  lymph.  This  current,  if  it  rises  to  the  surface  of  the 
body  and  appears  on  the  skin  or  mucous  membrane,  is  not  in  the  direction  of 
any  known  lymph  current  and  probably  is  a  reversal,  or  at  least  a  deflection, 
of  the  direction  of  the  adjoining  normal  lymph  currents.  Then,  too,  this 
phrase  seems  to  emphasize  a  phenomenon  that  many  surgeons  apparently  ig- 


=Hertzler,  A.   E.:     The   Peritoneum,   St.  Louis,   1919,   C.  V.  Mosby  Company,  i,   251-253. 
^Horsley  and  Whitehead:     Jour.  Am.  Med.  Assn.,  March  13,  1915,  pp.  873-877;   Ilorsley,  J.   S.:     Ann. 
Surg.,  March,   1916,  pp.  277-279. 


SURGICAL   DRAINAGE  43 

nore.  The  phrase  ''outpoui-ing  of  lymph"  occurred  to  me  l)ut  this  sugf,'csts 
an  almost  instantaneous  process,  or  at  least  one  that  covers  a  very  short 
space  of  time. 

It  may  also  be  objected  that  ''lymph"  is  used  in  rather  a  loose  sense. 
I  have  employed  it  as  indicating  the  thin,  clear  fluid  that  is  found  in  the 
lymph  channels  and  spaces  of  the  body  and  that  infiltrates  the  tissues  in 
edema.  In  order  to  describe  the  phenomena  of  surgical  drainage  it  appears 
to  be  necessary  to  use  the  words  "lymph"  or  "serum"  to  indicate  such  fluids. 


CHAPTER  III 
TECHXIC,  SUTURES,  AND  INSTRUMENTS 

The  technic  of  an  operation  refers  to  the  mechanical  steps  of  the  procedure 
and  also  to  the  manner  in  Avhieh  the  operator  and  his  assistants  execute  these 
steps.  Before  the  institution  of  antiseptic  surgery,  and  particularly  be- 
fore general  anesthetics  were  introduced,  the  time  consumed  in  performing 
the  operation  and  the  style  in  which  the  operator  worked  were  considered 
extremely  important.  Naturally,  with  a  suffering  patient  without  an  anes- 
thetic it  was  highly  important  to  complete  the  operation  as  soon  as  possible. 
It  was  also  found  in  preanesthetic  days  that  a  quick  operation  was  usually 
more  successful  than  one  that  was  prolonged.  In  order  to  operate  as 
quickly  as  possible,  certain  movements,  methods  of  holding  the  knife,  and 
of  securing  vessels,  were  considered  good  form,  without  which  the  proper 
speed  could  not  be  obtained.  This  is  similar  to  athletic  games,  as  in  tennis, 
golf  or  base  ball,  where  the  tennis  racket,  golf  stick,  or  bat  must  be  held 
in  such  a  position  or  sAvung  in  a  certain  manner  in  order  to  secure  the  ap- 
proval of  experts  on  form. 

AVhen  the  surgeon  made  a  practice  of  washing  his  hands  only  after  the 
operation  and  when  instruments,  hands  and  everything  that  came  in  contact 
with  the  wound,  were  loaded  with  bacteria,  naturally  the  quicker  the  oper- 
ation was  done  the  better  it  would  be  for  the  patient,  because  the  longer 
the  Avound  was  exposed  to  the  septic  hands  of  the  surgeon  or  to  the  infected 
instruments  or  sponges,  the  greater  would  be  the  infection.  Quick  surgery  in 
such  instances  was  justly  considered  a  vital  necessity.  There  is  not  the  same 
demand,  however,  for  speed  since  the  development  of  anesthetics  and  aseptic 
surgery.  It  is  infinitely  more  important  to  do  a  clean  operation  gently  than 
it  is  to  do  a  rough  operation  quickly.  The  operation  should  be  completed, 
however,  as  soon  as  is  consistent  with  thoroughness,  gentleness  and  the  com- 
plete application  of  the  principles  of  aseptic  surgery. 

The  instruments  used  should,  of  course,  be  such  as  may  be  needed  in  the 
performance  of  an  operation,  but  effort  should  be  made  to  use  no  more  in- 
struments than  are  necessary.  Special  instruments  always  carry  the  neces- 
sity of  proving  their  worth.  If  an  operation  can  be  satisfactorily  done  Avith  a 
sharp  knife  and  sharp  scissors  and  careful  manipulations,  there  is  no  real 
need  for  special  instruments,  even  though  some  surgeons  require  them.  It  is 
essential  to  have  instruments  that  are  reliable  and  of  good  quality.  It  is  not 
only  provoking  to  the  surgeon  to  have  a  dull  knife  and  dull  scissors,  but  it 
is  unfortunate  for  the  patient.  In  dissections,  particularly  around  large 
vessels,  dull  instruments  are  dangerous,  because  undue  effort  has  to  be  made 

4-i 


TECHXIC,    SUTURES,    AND    INSTRUMENTS  45 

with  dull  iiistriinionts  to  divide  tissues  where  merely  a  gentle  stroke  of  a 
sharp  knife  is  all  that  is  necessary.  Consequently,  the  force  and  direction 
of  the  cut  Avith  a  dull  knife  or  scissors  cannot  always  be  as  accurately  <ia^-ed 
as  with  a  sharp  instrument.  At  one  time  it  was  faslii()nal)Ie  to  have  forceps 
and  scissors  constructed  Avith  so-called  aseptic  locks,  so  they  could  be  taken 
apart  easily  and  cleaned.  Such  instruments  frequently  fell  apart  while  they 
were  being-  used  and  the  joints  soon  permitted  such  play  as  to  make  the  in- 
struments useless.  Forceps  and  scissors  can  be  joined  by  screw  locks  and 
cleaned  and  thoroughly  sterilized  by  boiling. 

Suture  or  ligature  materials  are  used  in  almost  every  operation.  There 
is  great  difference  of  opinion  as  to  choice  of  suture  material  and  much  is 
left  to  the  individual  surgeon's  judgment.  The  sutures  usually  employed 
are  silk,  silkworm-gut,  horsehair,  linen,  catgut,  kangaroo  tendons,  silver  wire, 
and  bronze  Avire.  There  are  certain  operations  in  Avhich  there  is  almost  una- 
nimity of  opinion  among  surgeons  as  to  the  type  of  suture  material  to  be  used. 
In  most  instances,  hoAvever,  the  difference  of  choice  is  marked.  ]Many 
operators  use  catgut  for  almost  everything.  The  former  objection  to  cat- 
gut, that  it  could  not  be  properly  sterilized,  hardly  exists  to-day.  It  is  true 
that  sterilization  of  catgut  is  more  difficult  than  sterilization  of  the  non- 
absorbable suture  materials  Avhich  may  be  boiled.  By  elaborate  processes  and 
repeated  sterilization,  hoAveA^er,  catgut  can  be  made  entirely  safe  from  the 
standpoint  of  sterility.  Its  rate  of  absorption  can  also  be  regulated  to  some 
extent  by  the  size  of  the  strand  used,  but  particularly  by  impregnating  the 
catgut  Avith  chemicals  that  make  it  resist  absorption.  The  tAvo  most  used  of 
these  are  chromic  acid  products  and  tannin.  They  are  also  used  in  curing 
leather.  By  regulating  the  strength  of  the  solution  of  these  chemicals  and  the 
time  during  Avhich  the  catgut  is  exposed  to  the  solutions  A^arying  rates  of 
absorbability  are  produced.  These  rates,  hoAvcA^er,  are  not  entirely  accurate. 
The  chief  objection  to  catgut  these  days  is  that  it  is  irritating  to  the  tissues, 
particularly  Avhen  impregnated  Avith  iodine,  and  causes  more  reaction  than  do 
nonabsorbable  sutures.  If  the  catgut  is  not  impregnated  AA-ith  some  antiseptic 
it  soon  becomes  a  culture  medium,  and  if  the  Avound  has  been  contaminated  or 
if  there  is  a  hematogenous  infection  the  catgut  may  become  the  center  of  sup- 
puration. When  catgut  is  used  in  the  mucosa  of  the  gastrointestinal  tract,  it  is, 
of  course,  rapidly  absorbed,  but  if  it  is  buried  by  successive  layers,  properly 
selected  and  applied,  it  Avill  hold  a  sufficient  length  of  time  for  union 
to  take  place.  It  has  an  adA'antage  in  operations  upon  the  stomach,  in  that 
it  is  in  the  course  of  time  completely  absorbed  if  not  too  strongly  tanned  or 
chromicized,  Avhereas  if  silk  or  linen  are  used  they  are  extruded  toAvard  the 
lumen  of  the  stomach  and  sometimes  become  entangled  in  the  mucosa  and 
form  a  source  of  infection  and  continued  irritation.  In  the  vaginal  mucous 
membrane  catgut  is  not  absorbed  so  quickly  as  in  the  gastrointestinal  tract, 
but  much  more  rapidly  than  in  skin  or  muscle. 

Xonabsorbable  sutures  Avhen  buried  often  give  trouble.  It  is  not  uncom- 
mon to  find  sinuses  that  occur  months  after  operations,  when  buried  non- 


46  OPERATIVE    SURGERY 

absorbable  sutvires  are  used  and  these  sinuses  will  not  heal  until  the  sutures 
are  removed.  In  buried  sutures,  particularly  in  operations  for  hernia,  it 
has  become  the  custom  to  use  absorbable  sutures,  tanned  or  chromic  catgut 
or  kangaroo  tendons.  If  nonabsorbable  sutures  are  employed  the  smallest 
strands  that  can  safely  be  used  should  be  chosen.  The  larger  the  bulk  of 
material  the  more  the  likelihood  of  trouble  and  sinus  formation.  When  very 
fine  silk  is  used  to  tie  vessels  and  the  aseptic  technic  is  perfect,  no  trouble  may 
result  from  the  nonabsorbable  suture,  and  in  time  such  fine  strands  are  ab- 
sorbed or  encapsulated.  The  majority  of  surgeons,  however,  find  that  for 
all  buried  sutures  or  ligatures  absorbable  material  is,  in  the  end,  more  satis- 
factory. 

In  plastic  work,  catgut  is  not  the  ideal  suture  material.  Its  tendency 
to  cause  considerable  reaction  during  the  healing  of  tissues  makes  more 
exudate  and  frequently  results  in  a  more  conspicuous  scar  than  is  ob- 
tained when  nonabsorbable  material,  such  as  fine  silkAvorm-gut,  silk,  or  horse- 
hair is  used.  There  is  not  the  same  excuse  for  using  catgut  on  the  surface 
of  the  wound,  where  it  can  be  easily  removed,  as  when  a  suture  or  ligature 
must  be  buried.  Fine  plastic  work  on  the  skin,  Avhere  an  inconspicuous  scar 
is  desired,  calls  for  nonabsorbable  sutures. 

When  catgut  is  used  in  buried  sutures  the  smallest  strand  that  will  do 
the  work  should  always  be  selected.  For  ligating  most  bleeding  points,  00 
plain  catgut  is  sufficient.  It  must  be  remembered  that  catgut  is  absorbed 
and  the  larger  the  strand  the  greater  the  burden  of  absorption  placed  upon 
the  tissue.  In  addition  to  this,  a  fine  strand  of  any  material  holds  the  knot 
better  than  a  coarse  strand.  There  is  less  likelihood  of  the  knot  slipping  in  a 
fine  strand  because  there  is  more  friction,  due  to  greater  surface  compared 
with  cubical  contents  in  the  smaller  strand.  It  is  better  to  use  two  fine 
strands  of  catgut  than  one  large  one  because  they  can  be  more  readily  ab- 
sorbed. It  is  important  in  all  sutures  not  to  tie  the  knot  too  tightly  so  as  to 
constrict  tissues  unduly.    This  is  particularly  true  of  catgut. 

Besides  plastic  work,  special  suture  material  is  indicated  in  special  re- 
gions. Marion  Sims'  well-known  experiments  showed  that  silver  Avire  was 
the  only  material  with  which  he  could  satisfactorily  repair  a  vesicovaginal 
fistula.  This  is  not  only  because  it  can  be  handled  easily,  and  nicely  ad- 
justed, but  because  metallic  silver  itself  is  mildly  antiseptic  and  has  no 
capillary  action.  Improved  aseptic  methods  permit  other  suturing  material 
to  be  used  in  repairing  these  fistulas  but  the  lesson  taught  by  Sims  is 
frequently  neglected.  Fine  silver  wire,  28  or  30,  is  exceedingly  useful  in 
cleft  palate  operations. 

For  bone,  stouter  suturing  material  must  be  used.  Some  have  recom- 
mended heavy  kangaroo  tendon,  but  with  the  mechanical  friction  with  sharp 
edges  of  bone  these  tendons  may  not  hold  long  enough.  Moderately  stout 
wire,  particularly  a  cable  of  fine  bronze  wire,  is  especially  suited  for  work 


TECHNIC,    SUTURES,    AND    INSTRUMENTS 


47 


on  bone,  though  where  the  strain  is  not  great,  tendon   or  tanned  catgut  is 
satisfactory. 

When  through-and-through  sutures  are  used  in  tiie  abdomen  nonab- 
sorbable sutures  shouUl  always  be  employed.  Silkworm-gut  is  excellent  here, 
though  stout  silver  wire  is  used  by  many  surgeons  and  has  the  advantage  of 
being  mildly  antiseptic. 

For  suture  material  in  the  intestines,  I  prefer  linen  or  silk,  though  some 
surgeons  use  catgut.  The  nonabsorbable  suture  seems  to  be  extruded  into  the 
lumen  of  the  intestine  and  rarely,  if  ever,  causes  trouble.  If  a  single  line  of 
sutures  is  used  in  operations  upon  the  intestine  and  catgut  is  employed  it 
may  be  absorbed  too  soon  and  perforation  result.  This  is  because  in  order  to 
secure  a  tirm  hold  in  intestinal  suturing  it  is  necessary  to  catch  the  submu- 
cous coat  or  to  penetrate  into  the  lumen  of  the  intestine.     Where  the  suture 


Fig.    1. — Reef   or   flat   knot. 


Fig.   2. — "Granny"  knot. 


penetrates  into  the  lumen  the  rate  of  absorption  of  catgut  would  be  so  rapid 
as  probably  to  be  unsafe  unless  the  catgut  was  tanned  or  chromicized  to  such 
an  extent  as  to  make  it  practically  a  nonabsorbable  suture. 

When  a  suture  material  is  used  as  a  drain  for  a  long  period  of  time,  as 
in  turning  a  salivary  tistula  of  the  parotid  into  the  mouth,  silver  wire 
should  always  be  the  choice  because  it  is  not  only  easily  handled,  but  its 
antiseptic  properties  tend  to  keep  the  wound  clean. 

The  thick  walls  of  the  stomach  permit  the  use  of  catgut  when  there  are 
several  layers  of  sutures  and  M'hen  at  least  one  of  these  layers  is  not  in  con- 
tact with  the  mucosa. 

One  of  the  most  important  procedures  in  the  technic  of  surgery  is  tying 
knots.  This  can  be  done  by  any  method  that  the  operator  finds  best  suited 
to  his  individual  requirements  (Figs.  1  and  2.).  The  all  important  point,  as 
taught  bv  the  old  authorities,  of  making  every  knot  a  reef  or  flat  knot  has 


48  OPERATIVE   SURGERY 

been  greatly  exaggerated,  but  undoubtedly  a  reef  knot  does  hold  better  than 
the  "granny  knot."  The  surgeon's  knot  consists  of  a  double  turn  in  the 
first  tie  and  a  single  turn  in  the  second.  The  double  turn  in  the  first  tie 
secures  the  thread  so  that  the  second  tie  can  be  run  down  without  the  first 
slipping.  The  fallacy  in  this,  however,  is  that  when  two  wraps  or  turns 
are  made  instead  of  one  it  is  more  difficult  to  run  the  first  tie  down  smoothly 
and  it  is  hard  to  tell  how  much  pressure  is  being  made  on  the  tissues  and 
how  much  is  being  taken  up  by  the  extra  friction  of  the  double  Avrap.  As 
Eoyster  says  of  the  surgeon's  knot:  ''the  surgeon's  knot  is  a  knot  that  the 
surgeon  does  not  use."  In  order  to  secure  accuracy  in  tying  large  vessels 
or  in  mass  ligatures,  it  is  much  better  to  make  merely  a  single  wrap  as  in  the 
reef  knot  and  while  this  is  tight  have  it  held  firmly  with  a  mosquito  hemo- 
static forceps,  which  is  strong  enough  to  prevent  the  tie  from  slipping  and 
at  the  same  time  is  not  strong  enough  to  injure  the  thread.  The  second  tie 
can  then  be  run  doAvn  easily.  In  any  important  suture  or  ligature  it  is  best 
to  make  three  ties  to  the  knot  in.stead  of  two.  Then  the  knot  will  hold 
whether  it  is  a  "granny"  or  a  reef  knot. 

In  making  a  knot  it  is  well  to  cultivate  the  art  of  tying  it  with  one  hand, 
as  it  frequently  saves  time  and  suture  material.  ;  The  finer  the  strand  used 
for  suture  or  ligature  the  more  likely  the  knot  is  to  hold,  because  there  is  more 
friction,  as  the  surface  of  the  fine  strand  is  greater  in  proportion  to  its  cubi- 
cal contents  than  in  the  coarser  strand. 

The  reef  knot  lies  fiat  because  the  loop  on  each  side  is  over  both  strands 
of  the  thread.  The  tying  of  the  reef  knot  can  be  best  accomplished  by  con- 
centrating the  attention  on  one  end  of  the  thread  and  disregarding  the 
other.  If  the  first  tie  of  the  knot  is  so  made  that  the  right  end  lies  away  from 
the  operator,  the  same  end  should  then  loop  over  the  left  end  in  Ihe  second 
tie  in  such  a  manner  that  it  crosses  the  left  end  from  above  dowuAvard  and 
towards  the  operator,  and  then  passes  through  beneath  the  loop  made  by 
the  left  end.  If  this  can  be  borne  in  mind  a  fiat  or  reef  knot  will  always 
result,  but  even  then,  it  might  be  vise  to  make  a  third  tie. 

A.  E.  Grant,  of  Utiea,  X.  Y.,  has  described  an  excellent  method  of  rapidly 
tying  a  knot  with  forceps  so  that  the  thread  need  not  be  touched  with  the 
hands  and  with  great  saving  of  suture  material.^  If  the  operator  wears  good 
rubber  gloves  there  is  no  objection,  from  the  standpoint  of  asepsis,  to  tying 
the  knot  with  the  hands,  but  not  infrequently  when  there  is  a  short  end  it  can 
be  tied  more  accurately  and  more  quickly  by  this  method  of  C4rant  than  Avith 
the  fingers.  It  is  also  useful  for  tying  in  deep  cavities  where  the  fingers  or 
hands  cannot  readily  reach  (Figs.  3,  4,  5.  6.  7.  8,  9  and  10..  The  teehnic 
as  described  by  Grant  is  as  follows : 

If  the  knot  is  to  be  tied  in  a  transfixion  .suture  or  ligature,  first  transfix 
the  tissues  with  the  needle,  which  must  be  puUed  through  with  forceps,  and 
catch  the  suture  near  the  needle  with  forceps  in  the  left  hand.     Pull  on  the 


lAnn.   Surg.,  April,  1918,  p.  439. 


TECHNIC,    SUTURES,    AND    INSTRUMENTS 


49 


thread  until  the  right  hand  short  end  is  only  al)out  one-half  inch  long.  The 
long-  end  should  be  proximal  and  the  short  end  distal  to  the  operator.  Lay 
the  point  of  the  needle  holder  across  and  on  top  of  the  suture  just  below 
the  point  Avhere  the  ■  suture  is  being  held  Avitli  thumb  forceps  pointing  up- 
ward toward  the  tip  of  the  thumb  forceps,  and  make  a  loop  as  showii  in  the 


3. — Grant's  method  of  tying  knot  with  for- 
ceps. The  suture  has  been  passed  and  forceps 
laid  to   the   right   of   the   thread. 


Fig.    4. — Forceps   have   made   a   loop   in   the   thread, 
with  the  nose  of  the   forceps   up. 


Fig.   5. — The  tip  of  the  thread  is 
forceps. 


jrasped  with 


Pig.  6. — The  thread  is  pulled  through,  forming  the 
first   tie   of   the   knot. 


illustration.  Then  catch  the  short  end  of  the  suture  with  the  tip  of  the  needle 
holder  and  pull  the  short  end  through  the  loop  while  the  left  hand  holds  the 
long  end  of  the  suture  taut  with  the  thumb  forceps.  Xext  place  the  needle 
holder  heneath  the  suture  and  make  a  second  loop,  catching  the  short  end  as 
before.     This  alwavs  results  in  a  reef  or  flat  knot. 


50 


OPERATIVE    SURGERY 


Knots  can  be  tied  quickly  in  this  way,  witli  short  ends  and  willi  a  minimum 
amount  of  materiah  They  can  also  be  made  in  cavities  iu  Avhieh  it  is  difficult 
or  impossible  to  use  the  hand  or  fingers. 


Fig.  7. — The  second  loop  is  made  with  forceps, 
this  time  with  the  forceps  to  the  left  on  the  under 
side  of  the   thread. 


Fig.    8. — The   loop   has   been    completed. 


Fig.    9. — The   tip    of   the   thread    is   drawn   through. 


Fig.   10. — The  second  tie   of  the  knot   is  completed, 
making   a    reef   knot. 


CHAPTER  IV 

OOMPLICATIONS  OF  OPERATIONS;  INFECTION,  SHOCK  AND 

HEMORRHAGE 

Infection,  shock  and  hemorrhage,  while  different  entities,  are  not  infre- 
quently associated.  Hemorrhage  during  an  extensive  operation  often  results 
in  shock,  and  if  the  patient's  resistance  is  lowered  by  hemorrhage  and  shock, 
infection  is  likely  to  occur.  All  three  of  these  undesirable  complications  can, 
in  the  vast  majority  of  cases,  be  guarded  against  by  a  proper  consideration 
of  the  operative  procedure  before  it  is  begun  and  by  its  careful  execution. 
Infection,  of  course,  is  wrapped  up  with  the  history  of  antiseptic  and  aseptic 
surgery,  which  was  begun  by  Lord  Lister  in  the  seventies,  and  has  gradually 
developed  through  a  series  of  stages  to  the  present  technic.  While  the  pres- 
ent technic  is  a  great  improvement  over  what  has  gone  before,  it  cannot  be 
considered  ideal. 

If  infection  follows  an  operation  on  previously  uninfected  tissues  it 
should  be  a  source  of  deep  concern  to  the  surgeon  and  his  associates.  While  it 
is  true  that  in  a  large  series  of  cases  a  small  percentage  of  infection  will 
occur  even  under  the  best  conditions,  this  is  no  excuse  for  a  careless  regard 
of  those  infections  that  do  take  place.  Still  less  should  it  be  an  excuse 
in  other  hands  for  a  larger  percentage  of  infections. 

It  is  impossible  to  have  an  iron-bound  technic  for  every  surgeon,  but 
there  are  certain  principles  which  he  should  follow  if  his  work  is  to  be  rea- 
sonably free  from  sepsis.  The  consideration  of  the  patient,  his  general  con- 
dition, the  presence  of  sore  throat,  or  a  focus  of  infection  elsewhere  or  the 
prevalence  of  an  epidemic,  such  as  influenza,  should  be  carefully  considered 
before  deciding  upon  operation.  During  epidemics  of  influenza  many  surgi- 
cal disasters  have  occurred  by  operating  upon  patients  who  were  at  the  time 
of  operation  apparently  free  from  influenza,  but  who  had  a  slight  sore  throat. 
In  the  reports^  of  streptococcic  infection  at  Camp  Custer,  Mich.,  a  number  of 
cases  are  cited  in  which  operations  that  were  done  with  apparently  perfect 
aseptic  technic  resulted  in  infection  and  other  instances  occurred  in  which 
even  after  the  wound  had  almost  healed  a  streptococcic  infection,  usually  by  the 
streptococcus  hemolyticus,  occurred.  This  was  thought  to  be  a  hematogenous 
infection  and  in  every  case  cultures  from  the  throat  showed  the  same  type  of 
streptococcus  that  infected  the  w^ound.  To  operate  upon  a  cleft  palate,  for 
instance,  in  the  presence  of  a  sore  throat  or  bad  teeth  is  surely  inviting  infec- 
tion to  the  wound.  The  environment  of  the  operation  and  patient  must  be 
considered.     Dust  infection  has  been  regarded  too  lightly  in  recent  years, 

lillnton,   Burhans  and  Hunter:     Jour.   Am.   Med.   Assn.,   May   24,    1919,   Ixxii,    1520-1524. 

51 


O^  OPERATIVE    SURGERY 

and  more  effort  should  be  nuide  to  avoid  it.  The  location  of  the  operating 
room  with  regard  to  drafts  of  air  is  iiii])or1aiit.  The  operating  room  should 
be  on  the  top  floor  of  the  hospital  and  as  isolated  as  possible  from  the  rest 
of  the  hospital.  It  should,  of  course,  be  so  furnished  and  equipped  that  it 
can  l)e  readily  cleaned,  and  while  it  should  be  comfortable,  asepsis  must 
not  be  sacrificed  for  comfort.  A  cliaiKlclii'i-  1liat  bangs  over  the  Mouiid  is  al- 
Avays  a  potential  source  of  dust  infection.  It  is  difficult  to  clean  and  the 
least  touch  or  jar  is  likely  to  send  down  myriads  of  particles  of  dust  into  the 
wound  beneath.  The  artificial  lighting  of  the  operating  room  should  pref- 
erably be  on  cranes  that  can  be  swung  out  of  the  way  during  the  day  time. 

With  some  surgeons  it  is  a  practice  that  the  fingers  even  when  incased  in 
sterile  rubber  gloves  should  never  touch  the  wound.  That  a  wound  should  not  be 
unnecessarily  handled  with  the  fingers  and  that  bone  should  be  manipulated 
chiefl}',  if  not  entirely,  with  instruments  is  obvious;  but  the  resistance  of  the  tis- 
sues of  the  patient  must  always  be  kept  in  mind  and  gentle  fingers  in  sterile  rub- 
ber gloves  will  do  less  damage  to  tissues  and  so  conserve  the  patient's  natural 
defenses  to  a  greater  extent  than  bruising  and  crushing  with  steel  forceps.  If  a 
rubber  glove  has  no  holes  and  has  been  boiled  it  is  just  as  sterile,  if  there  be  de- 
grees in  sterility,  as  any  steel  instrument  can  be.  Every  time  tissues  are  unnec- 
essarily mashed  or  squeezed  there  is  an  added  burden  placed  upon  the  tissues 
in  making  repair  and  the  slightest  infection  from  air  or  elsewhere  will  find  a 
ready  culture  medium. 

The  margins  of  the  skin  or  mucous  membrane  are  prolific  sources  of  mild 
infection.  It  is  always  best  to  cut  through  the  skin  or  mucous  membrane  with  a 
knife  and  then  lay  it  aside,  because  it  is  imi^ossible  to  sterilize  the  deep  laj-ers 
of  the  skin  by  any  process  that  will  not  destroy  the  skin.  If  the  edges  of  the 
skin  or  mucous  membrane  are  caught  with  hemostatic  forceps  or  bruised  by 
handling  with  heavy  thumb  forceps,  not  only  is  tissue  injured  thereby,  but  the 
staphylococcus  albus,  whose  normal  habitat  is  in  the  hair  follicles  and  sweat 
and  sebaceous  glands,  may  be  squeezed  into  the  wound  and  cause  an  infec- 
tion, or  at  least  retard  healing  (Fig.  11.).  This  is  probably  one  cause  of  the 
so-called  stitch  infection.  While  the  -staphylococcus  albus  is  the  normal  in- 
habitant of  hair  follicles  and  sebaceous  and  sweat  glands,  if  injured  tissue  is 
inoculated  by  these  germs,  infection  may  ensue  just  as  infection  occurs  from 
the  colon  bacillus  whose  normal  habitat  is  the  colon. 

In  bone  operations  it  is  best  to  handle  the  bone  as  far  as  possible  with 
metal  instruments  because  bone  can  be  so  manipulated  without  injuring  it 
and  for  the  further  reason  that  the  sharp  spicules  of  bone  are  likely  to  punc- 
ture the  rubber  glove  of  the  operator.  In  soft  tissues,  however,  if  the  operator 
is  sure  of  his  gloves  and  handling  of  the  wound  must  be  done,  it  is  much  better 
to  do  it  with  a  gloved  hand  than  with  steel  instruments.  It  is  doubtful 
if  any  operative  wound  can  be  considered  free  fi-om  bacteria  if  the  operation 
lasts  an  hour.  If  no  virulent  pathogenic  bacteria  have  been  introduced  dur- 
ing the  operation  and  if  the  wound  has  been  handled  gently  and  without 
too   much   damage,   the   few    germs   that    do    gain   access   to   tl'e    wound   can 


COMPLICATIONS 


53 


ordinarily  be  taken  (.-are  of  by  the  natural  defenses  of  the  tissue.  A  large 
petri  dish  containing  a  sterile  culture  medium,  exposed  on  the  instrument 
table  during  the  time  of  operation  and  covered  and  cultured  later,  will  al- 
most invariably  show  a  few  colonies  of  bacteria.  If  these  have  dropped  from 
the  air  into  this  culture  medium,  it  is  at  least  probable  that  the  Avound  has 
received  the  same  infection.     This  makes  it  all  the  more  important  not  only 


Fig.  11. — Control  of  hemorrhage  in  abdo.Tiinal  incision  by  whipping  over  the  muscle  with  catgut.     This  draw- 
ing also   shows  method  of  catching  vessels   without  including  the   skin   in  the  bite  of   the   forceps. 


54  OPERATIVE    SURGERY 

to  conduct  the  operation  according  to  a  sterile  technic,  but  to  preserve  by 
gentle  work  the  natural  defenses  of  the  tissues. 

The  fad  of  not  touching  the  wound  with  the  gloved  hand  sometimes  be- 
comes almost  absurd.  I  have  seen  moving  pictures  of  a  hernia  operation  done 
by  a  surgeon  who  claims  that  the  fingers  should  never  touch  the  Avound 
because  of  their  liability  to  carry  infection.  The  literal  part  of  the  technic, 
so  far  as  the  operator  was  concerned,  was  well  carried  out,  and  yet  the 
screen  showed  that  the  blood  vessels  that  had  been  carefully  grasped  with 
forceps  were  tied  with  catgut  applied  by  the  fingers  of  the  assistant  who  was 
probably  an  intern,  and  we  know  that  the  intern  is  often  the  "goat"  for  cases 
that  become  infected  after  operation. 

In  intestinal  suturing  often  no  attempt  is  made  to  sterilize  the  mucosa 
of  the  incised  intestine.  This  is  probably  not  essential  in  stomach  surgery 
or  in  the  duodenum  or  upper  jejunum,  as  but  few  pathologic  bacteria  are 
found  in  this  region,  but  the  ileum  and  the  colon  teem  with  bacteria  of  in- 
fection and  it  seems  just  as  essential  to  clean  the  ends  of  the  bowel  which 
are  to  be  united  and  mop  them  with  some  antiseptic  solution  as  it  is  to  clean 
a  dirty  skin  before  incising  it.  An  intestinal  suture  to  be  safe  must  pene- 
trate into  the  lumen  of  the  bowel.  If  no  effort  is  made  to  disinfect  that  lumen 
the  needle  and  thread  become  very  common  carriers  of  germs  and  smear 
bacteria  wherever  they  touch.  There  are  other  important  details  of  avoiding 
infection  in  intestinal  suturing,  which  will  be  considered  in  Chapter  XXVI 
on  Intestinal  Surgery. 

After  every  infection  in  a  clean  wound  the  surgeon  and  his  operating 
staff  should  go  over  the  case  carefully,  have  a  bacteriologic  examination 
made  of  the  pus  and  make  an  honest  effort  to  fix  the  responsibility  for  the 
infection.  While  it  is  natural  to  expect  that  errors  of  technic  come  chiefly 
from  inexperienced  assistants  and  nurses,  the  operator  should  by  no  means 
consider  himself  infallible  and  if  he  is  unwilling  to  take  the  blame  when  he 
is  obviously  at  fault,  the  investigation  will  be  more  harmful  than  beneficial. 

Shock,  except  in  traumatic  surgery,  is  rarely  seen  in  the  modern  operating 
room.  In  some  cases  where  the  operative  risks  are  great  and  the  patient's 
condition  will  not  permit  of  delay,  shock  may  occur.  Every  surgeon  with 
sufficiently  extensive  experience  will  sometimes  encounter  cases  in  which 
unexpected  things  happen  during  an  operation,  or  in  which  the  patient  reacts 
in  an  unaccountable  manner,  and  may  be  faced  with  unexpected  shock. 

The  etiology  of  shock  has  caused  much  discussion,  especially  in  the  last 
few  years.  Crile  holds  that  it  is  due  to  nocuous  impulses  that  travel  over 
the  afferent  nerves  to  the  brain  and  are  initiated  by  the  trauma  of  the  op- 
eration or  injury.  It  is  undoubtedly  true  that  certain  reflexes  occur  after 
nerve  trauma  with  great  promptness.  Injuries  to  the  testicle  or  blows  in  the 
epigastrium  or  manipulation  of  the  mucosa  of  the  larynx  may  be  followed  by 
collapse,  or  by  greatly  impaired  heart  action,  or  even  by  death.  This,  too, 
may  occur  where  there  is  but  little  if  any  evidence  of  an  organic  lesion. 
This  type  of  collapse  seems  somewhat  different  from  the  picture  of  shock. 


COMPLICATIONS  55 

The  reports  of  the  coinmitlee  of  medical  research  dui-iiio-  the  Workl  War 
seem  to  indicate,  as  has  been  claimed  by  Cannon,  tliat  traumatic  shock 
is  due  to  the  absorption  of  the  products  of  traumatized  tissue.  Cannon  has 
Avritten  interesting  papers  on  this  subject.  Whether  we  hold  with  Crile  on 
the  nervous  theory  of  traumatic  shock,  or  with  Cannon  that  it  is  a  traumatic 
toxemia,  it  is  equally  true  that  gentle  surgery  is  always  demanded  to  prevent 
shock  or  to  reduce  it  to  a  minimum.  In  this  way  the  nocuous  nerve  impulses, 
as  claimed  by  Crile,  would  be  lessened ;  or  if  we  hold  to  the  traumatic  toxemia 
theory  of  shock,  gentle  surgery  would  produce  a  much  smaller  amount  of  this 
toxic  material  than  would  rough  surgeiy. 

Certain  individuals  are  more  likely  to  be  shocked  than  others.  They 
seem  to  react  more  readily  to  the  causes  of  shock.  Conditions  that  may 
produce  profound  shock  in  some  patients  may  cause  but  little  disturbance  in 
others.  This,  of  course,  is  no  excuse  for  neglecting  precautions,  but  on  the  other 
hand  should  make  us  more  guarded  because  of  the  inability  to  tell  just  how 
any  given  patient  will  react  to  a  certain  trauma. 

Keith-  has  called  attention  to  the  great  prognostic  value  of  hemoglobin  esti- 
mations in  shock.  He  says  that  when  dilution  is  taking  place  satisfactorily 
the  hemoglobin  falls,  but  if  the  fluid  is  not  retained  in  the  vascular  system 
the  percentage  of  hemoglobin  decreases  but  little  if  any,  and  may  even  rise. 
If  the  hemoglobin  rises  the  prognosis  is  exceedingl.y  serious  because  it  shows 
that  the  capillaries  and  small  blood  vessels  are  leaking  to  such  an  extent 
that  the  corpuscles  of  the  blood  are  becoming  concentrated  Avithin  the  blood 
vessels.  After  a  few  days,  if  dilution  has  taken  place  and  hemoglobin  per- 
centage has  dropped  to  30  or  40,  transfusion  of  blood  may  become  essential, 
particularly  if  a  surgical  operation  has  to  be  performed,  for  such  patients  are 
prone  to  develop  shock  a  second  time  if  the  hemoglobin  is  low.  When 
operation  must  be  done  in  the  presence  of  shock  or  when  the  occurrence  of 
shock  is  probable,  nitrous  oxide  and  oxygen  anesthesia  should  be  the  anesthetic 
of  choice.  This  anesthetic  is  less  likely  to  produce  shock  than  any  other 
general  anesthetic. 

It  has  been  found  that  acidosis  is  present  in  shock  and  at  one  time  it 
was  thought  that  great  results  could  be  accomplished  by  treatment  along  this 
line.  Acidosis  in  shock,  however,  is  probably  a  terminal,  or  at  least  a  late 
condition,  and  while  administration  of  bicarbonate  of  soda  is  indicated  it 
should  be  only  one  of  the  measures  used.  The  patient  should  be  kept  quiet 
and  warm  and  should  be  well  under  the  influence  of  morphine.  Mangled 
tissue,  if  in  a  limb,  should  be  excised  gently  and  as  quickly  as  possible. 
If  there  has  also  been  loss  of  blood  an  abundance  of  water  should  be  given 
by  mouth,  soda  and  glucose  solution  by  enemas,  or,  if  the  need  is  more  urgent, 
hypodermoclysis  of  Locke's  solution  should  be  administered.  If  this  does 
not  result  in  improvement  of  the  patient's  condition,  transfusion  of  blood 
should  be  done. 


=Keith,    N.    M.:     Report    of    a    Special    Investigation    Committee    on    Surgical    Shock,    Special    Report, 
Series  No.  26,  London,   1919,  p.   43. 


56  OPERATIVE    SURGERY 

It  must  be  remembered  that  in  shock  the  fluid  of  the  ])lood  seems  to  accu- 
mulate in  and  around  the  capillaries  and  Dial  the  patient  suffers  from  lack 
of  circulating-  blood  just  as  much  as  after  hemorrhage.  The  difference,  however, 
is  that  on  account  of  this  tendency  for  the  capillaries^  to  leak  unduly,  fluid 
in  a  badly  shocked  patient  remains  but  a  short  time  in  the  circulating  vascu- 
lar S3'stem. 

Hemorrhage  and  shock  are  often  closely  allied,  and  the  trinity  of  hemor- 
rhage, shock  and  infection  is  a  formidable  combination.  For  years,  Halsted, 
of  Baltimore,  has  demonstrated  that  great  care  in  preventing  loss  of  blood  during 
a  surgical  operation  is  almost  a  preventive  of  shock  even  when  the  operation  is 
prolonged.  Bleeding  points  should  be  carefully  caught  and  wherever  possible 
liemostasis  should  be  complete  before  any  operation  has  been  concluded  (Fig.  11). 
In  some  operations  it  is  impossible  to  clamp  and  tie  each  vessel,  as  in  operations 
on  the  prostate,  but  in  such  instances  firm  packing  or  some  definite  pressure  suffi- 
cient to  check  the  bleeding  should  be  provided. 

Where  a  large  vessel  is  accidently  injured  during  an  operation,  if  it  is 
a  vein  it  can  readily  be  controlled  by  pressure.  If  the  vessel  has  been 
injured  in  only  one  place  pressure  should  be  made  with  a  small  piece  of 
gauze  or,  better  still,  with  the  finger.  This  should  be  gradually  Avithdrawn 
until  the  bleeding  point  is  accurately  located  and  clamped.  It  is  then  se- 
cured by  a  ligature,  preferably  in  a  needle.  If  the  bleeding  is  venous  and 
is  sudden  and  overwhelming,  a  large  piece  of  gauze  or  a  towel  should  be 
immediately  pressed  into  the  wound  and  held  until  the  bleeding  has  been  some- 
what checked.  It  is  then  gradually  withdrawn  until  the  source  of  the  hemorrhage 
is  exposed.  If  the  hemorrhage  comes  from  a  large  artery  such  pressure  will 
be  ineffective  and  the  vessel  can  best  be  sought  for  and  grasped  with  the  fingers 
until  the  field  is  cleared  and  a  clamp  applied.  This  is  better  than  the  blind 
application  of  a  clamp. 

W.  J.  Mayo  speaks  of  several  instances  in  which  the  renal  artery  had  re- 
-tracted  from  the  pedicle  after  nephrectomy  or  was  injured  during  the  opera- 
tion and  he  promptly  controlled  the  hemorrhage  by  first  grasping  the  artery 
with  his  fingers  and  then  clamping  it-.  In  such  a  large  vessel  pulsations  can 
be  easily  felt  and,  as  Mayo  says,  the  "artery  fairly  jumps  into  the  fingers", 
whereas  the  blind  application  of  forceps  in  a  bloody  field  maj^  do  great  dam- 
age. After  the  vessel  has  been  caught  with  the  fingers,  forceps  can  be  accu- 
rately applied,  and  the  artery  ligated. 

In  hemorrhage  from  operations  on  the  extremities,  pressure  shoidd  be 
made  over  the  femoral  or  the  brachial  artery,  or  a  tourni(|uet  applied,  but 
the  tourniquet  should  be  kept  in  place  no  longer  than  is  necessary  to  con- 
trol the  bleeding  vessel.  Small  points  of  bleeding  should,  when  possible, 
be  whipped  over  Avith  sutures,  preferably  of  catgut. 

In  abdominal  operations,  as  after  separating  pus  tubes,  often  a  large  area 
is  left  where  the  blood  seems  to  ooze  from  every  pore.  The  area  sometimes 
is  so  great  that  it  is  difficult  or  impossible  to  control  it  Avith  suturing  and  to 
suture  blindly  in  the   pelvis  is  fraught  with   clanger.     Packing,   if   abundant 


COMPLICATIONS  57 

aiiil  Irl'l  tod  loiiii',  may  be  t'ollDwrd  by  iiiaiiy  coinpl  iciil  idiis.  In  such  iiislaiicos, 
firm  pressure  ^\^\\h  dry  i;aii/r  on  Ihc  bb'cdin^'  area  sIkmiM  be  k('])t  \ip  for 
about  five  minutes;  Ibal  is,  i"or  a  little  longer  tiiaii  the  physioloyie  time 
for  the  blood  to  elot.  Then  the  a^auze  can  be  gradually  removed.  Frequently 
tlie  l)leediii<i'  will  lia\e  been  entirely  cheeked,  or  at  least  \\ill  be  reduced  to  a 
few  points  that  can  be  easily  and  safely  controlled  by  suture  or  ligature. 

Peroxide  of  hydrogen  tends  to  oxidize  and  break  up  the  blood  corpus- 
cles and  particularly  the  platelets.  Before  making  pressure  an  a])plieation 
of  a  small  amount  of  peroxide  of  hydrogen  Avill  cause  a  rapid  disintegra- 
tion of  the  platelets  and  blood  corpuscles  and  so  provide  an  abundance  of 
fibrin  ferment  to  promote  clotting. 

There  are  on  the  market  several  preparations  for  promoting  clotting, 
some  of  them  containing  fibrin  ferment  or  its  elements,  and  others  the  ex- 
tracts of  various  tissues.  Peroxide  of  hydrogen  provides  what  might  be 
called  an  autogenous  fibrin  ferment  in  abundance  and  is  preferable  to  the 
manufactured   products. 

Variations  of  posture  aid  greatly  in  the  control  of  hemorrhage  in  oper- 
ations on  the  head.  The  head  and  the  whole  body  may  be  elevated  to  les- 
sen bleeding  from  the  head  and  when  operating  upon  a  limb  advantage  may 
be  taken  of  changing  the  posture  if  the  application  of  a  tourniquet  is  con- 
sidered inadvisable.  Bleeding  is  greatly  lessened  by  elevating  a  limb.  "Where- 
ever  possible  the  application  of  a  tourniquet  should  be  avoided  except  in 
amputations  or  in  regions  of  the  limb  that  are  unusually  vascular.  In 
patients  of  low  resistance  a  tourniquet,  which  completely  deprives  the  tis- 
sues of  blood  for  a  period  of  an  hour  or  more,  is  a  serious  handicap  in 
the  healing  of  the  wound  and  if  a  careful  dissection  with  clamping  of  the 
individual  vessels  can  be  done,  the  eventual  results  will  be  much  better. 

Bleeding  from  bone,  as  in  operations  on  the  skull,  may  be  controlled  by 
the  application  of  bone  wax.  This  consists  of  bee's  wax,  7  parts;  almond 
oil,  1  part;  salicylic  acid,  1  part.  This  wax  is  antiseptic  and  absorbable 
and  can  be  pressed  firmly  into  the  bone,  so  plugging  up  the  bleeding  sinus. 

In  operations  upon  the  head  and  neck,  Dawbarn  formerly  advised  what 
he  termed  "sequestration  anemia."  He  applied  a  tourniquet  on  all  of  the 
extremities  close  to  the  body,  just  tight  enough  partially  to  obstruct  the 
venous  return  but  not  to  occlude  the  arteries.  Thus  a  passive  congestion  of 
the  extremities  is  produced  and  a  sufficient  amount  of  blood  is  supposed  to 
be  dammed  back  in  the  extremities  to  lower  the  general  blood  pressure  and 
consequently  decrease  the  bleeding  in  the  operative  field.  This,  however,  is  a 
dangerous  practice.  The  blood  pressure  is  undoubtedly  lowered  by  this 
procedure,  but  is  not  readily  restored  by  removing  the  tourniquet.  In  several 
instances  in  wdiich  I  operated  upon  the  gasserian  ganglion,  this  sequestration 
anemia  was  practiced,  and  toAvard  the  end  of  the  operation  the  patient  was 
in  a  mild  state  of  shock  from  which  he  did  not  recover  for  several  hours 
after  the  operation.  I  abandoned  the  practice  and  found  that  the  patients  did 
much  bgtter.    The  explanation  of  the  mild  shock  caused  in  these  cases  is  furnished 


58  OPERATIVE   SURGERY 

by  the  excellent  experimental  work  of  Frank  Mann,  of  the  Mayo  clinic, 
who  showed  that  deep  shock  can  be  produced  in  animals  by  obstructing  the 
venous  return  from  a  limb  while  the  artery  is  left  open. 

The  liability  of  hemorrhage  to  emerge  into  shock  must  alwaj^s  be  borne  in 
mind.  The  two  conditions  are  clinically  very  much  alike,  but  often  much  light 
is  thrown  upon  the  situation  by  a  careful  blood  count,  as  in  shock  without 
hemorrhage  the  red  cells  and  the  hemoglobin  are  not  lowered. 

The  operator  should  learn  that  he  can  control  any  hemorrhage  in  the 
vast  majority  of  cases  by  keeping  cool  and  using  common  sense.  In  any 
sudden  hemorrhage  that  comes  from  one  point  the  fingers  are  the  best  tem- 
porary means  of  controlling  the  bleeding.  If  the  bleeding  comes  from  sev- 
eral points,  packing  is  placed  and  gradually  removed  while  the  various  points 
are  grasped,  or  if  this  is  impossible  the  packing  may  be  left  for  a  little  time 
until  most  of  the  points  have  ceased  bleeding.  Tampons  for  permanent  con- 
trol of  hemorrhage  should  rarely  be  employed,  particularly  if  the  bleeding 
is  arterial. 

In  marked  hemorrhage  it  sometimes  becomes  a  nice  point  to  decide 
whether  general  treatment,  such  as  stimulation  or  intravenous  injection  of 
Locke's  solution  or  salt  solution  should  be  used.  If  the  blood  pressure  goes 
too  low  and  impairs  the  nutrition  of  the  vital  brain  cells  recovery  is  impos- 
sible. If,  on  the  other  hand,  the  patient  is  stimulated  too  much,  there  may  be 
a  tendency  for  the  hemorrhage  to  continue  because  of  the  increased  pressure 
in  the  bleeding  vessels. 

The  constitutional  treatment  consists  in  keeping  the  patient's  head  down 
in  an  attempt  to  adjust  the  blood  pressure  so  it  will  not  be  too  low  for  the 
brain.  But  the  pressure  must  not  be  so  high  as  to  encourage  the  bleeding. 
In  hemorrhage  the  immediate  effect  is  from  the  loss  of  volume  of  blood,  and 
hypodermoclysis  of  salt  solution  or,  better,  of  Locke's  solution,  can  readily 
restore  this.  If  there  is  urgency,  a  vein  may  be  opened  and  these  solutions 
given  intravenously.  If  the  volume  of  blood  lost  is  great,  transfusion  of 
blood  should  be  done.  Too  much  dependence  must  not  be  placed  upon  the 
percentage  of  hemoglobin  following  a  sudden  hemorrhage.  Sometimes  this 
percentage  is  abnormally  high  because  with  the  low  pressure  and  contracted 
vessels  enough  serum  has  not  been  absorbed  to  dilute  the  red  corpuscles  and 
it  may  be  several  hours  or  longer  before  the  hemoglobin  reaches  a  very  low 
point.  The  best  index  for  transfusion  after  a  sudden  severe  hemorrhage 
during  an  operation  when  the  patient  does  not  react  to  Locke's  or  salt  so- 
lution, is  the  clinical  condition  of  the  patient.  It  must  be  borne  in  mind  that 
too  great  a  depression  from  hemorrhage  may  result  in  shock  and  also  will 
invite  infection  even  if  the  patient's  life  is  saved. 


CHAPTER  V 

TRANSFUSION  OF  BLOOD 

The  teehiiic  of  traiisfusiou  of  blood  lias  undergone  many  changes  in 
the  last  feAV  years,  particularly  since  the  citrate  method  of  Lewisohn  has  be- 
come popular.  The  operation  of  transfusion  of  l)lood  is  an  old  one,  though 
it  has  been  used  in  a  practical  Avay,  only  Avithin  the  last  twenty  years.  The 
ideal  method  of  transfusing  blood,  would  be  to  transport  it  directly  from  the 
vascular  system  of  the  donor  to  the  blood  vessels  of  the  patient  over  the  vas- 
cular endothelium  without  break.  This  can  be  accomplished  by  uniting  the 
two  vascular  systems.  The  objections  to  this  method  are  the  difficulty  of  the 
technic,  the  inability  to  measure  the  dosage  accurately,  and  the  liability  of 
the  heart  of  the  patient  to  dilate  if  subjected  to  too  much  pressure  from 
the  direct  arterial  flow  of  the  donor. 

Transfusion  of  blood  may  be  classified  as:  (1)  Direct,  in  which  the  en- 
dothelium of  the  vascular  system  of  the  donor  is  directly  united  to  or  is 
in  contact  with  the  endothelium  of  the  vascular  system  of  the  patient.  (2) 
Semidirect,  in  which  the  vascular  system  of  the  donor  is  connected  to  the 
vascular  system  of  the  patient  by  a  tube  of  some  material  and  in  which  there 
is  a  break  in  the  continuity  of  the  vascular  endothelium.  (3)  Indirect,  in 
which  the  blood  of  the  donor  is  drained  into  a  receptacle  or  syringe  and  then 
transferred  to  the  patient,  either  with  or  Avithout  chemicals  to  prevent 
coagulation. 

Whatever  method  of  transfusion  is  used  it  is  essential,  except  in  the 
gravest  emergency,  to  secure  a  donor  Avhose  blood  Avill  be  congenial  Avith 
that  of  the  patient.  The  division  by  Moss  of  all  human  beings  into  four 
different  classes  so  far  as  the  reactions  of  the  blood  and  serum  are  concerned, 
has  been  generally  accepted.  The  tests  for  hemolysis,  and  particularly  for 
agglutination,  should  be  carefully  made.  With  recently  improved  laboratory 
technic  this  can  be  completed  in  a  fcAv  minutes  instead  of  taking  a  great 
many  hours  as  Avas  formerly  done.  The  blood  of  the  patient  and  the  blood 
of  the  donor  are  matched  or  tested  by  standardized  serum  and  assigned 
to  one  of  four  groups.  There  are  cases  of  great  urgency,  hoAvever.  in  AAdiicli 
even  this  short  time  cannot  be  spared.  In  such  instances  a  donor  AA'ho  is  pref- 
erably a  blood  relative  or,  if  not,  Avho  is  of  the  same  race,  should  be  selected. 
Care  should  be  taken,  of  course,  to  eliminate  the  presence  of  such  diseases  as 
syphilis  or  any  acute  infection  in  the  donor.  His  hemoglobin  and  red  and  AA'hite 
cell  count  should  be  recorded  as  Avell  as  his  blood  pressure,  in  order  to  check 
the  changes  that  may  occur  during  or  after  the  transfusion. 

The  direct  meiliod  is  best  represented  by  suturing  the  artery  of  the  donor 

59 


60 


OPERATIVE    SURGERY 


to  tlie  vein  of  the  patient.  This  can  be  done  by  the  technic  of  Carrel  or  by 
my  technic,  which  is  described  in  Chapter  YI  on  Suturing  Blood  Vessels. 
It  is  best  so  to  select  the  vein  of  the  patient  that  the  site  of  union  of  the 
vein  will  be  a  short  distance  from  a  small  branch  of  the  vein.  In  this  way  the 
small  branch  can  be  clamped  with  mosquito  forceps  and  if  there  is  obstruc- 
tion at  the  site  of  anastomosis  a  smooth  probe  anointed  with  vaseline  is  intro- 
duced through  the  small  branch,  passed  up  through  the  sutured  vessels,  and 
so  can  loosen  any  obstruction.     By  compressing  the  main  trunk  of  the  vein 


Fig.    12. — The   author's   method   of   transfusion   of   blood   with   the   arterial   suture   staff. 


just  proximal  to  the  small  branch,  the  obstructing  substance  is  forced  out 
through  this  branch  and  the  branch  is  again  clamped.  The  compression  on 
the  main  trunk  is  then  removed  and  the  current  of  blood  permitted  to  re- 
sume its  flow  into  the  venous  s^'stem  of  the  patient.  This  method,  while  it 
requires  time  and  experience  in  the  technic  of  blood  vessel  suturing,  is  very 
satisfactory^  (Fig.  12).  The  flow  should  be  permitted  to  continue  until  the 
hemoglobin  or  the  general  condition  of  the  patient  seems  sufficiently  im- 
proved or  until  the  condition  of  the  donor  shows  that  as  much  blood  has  been 
withdrawn  as  is  compatible  with  his  safety.  If  the  flow  is  occasionally  in- 
terrupted or  greatly  diminished  by  compressing  the  artery  with  the  thumb 
and  finger,  there  will  be  less  likelihood  of  dilatation  of  the  heart  and  the 


TRANSFUSION    OF    BLOOD 


61 


donor  Avill  stand  the  loss  of  l)]o()d  Ix^ttor  than  it'  llic  fnll   (low  of  tlic  artery 
is  continued  without  intermission. 

The  direct  method  can  also  be  employed  Avitli  the  cannula  of  Crile  or  some 
of  its  modifications.  This  cannula  which  is  modeled  on  the  tul)e  of  Payr, 
has  heen  variously  modified  (Figs.  13',  14,  15,  16  and  17).  Hepl)urn  has  in- 
troduced  a   modification    in   which   there   is   a   collar   with   four   perforations 


Fig.   13. 

Fig.  13. — Crile's  can- 
nula   for    transfusion. 


Fig.    14. 

Fig.    14. — The    vein    is    drawn    through    the    cannula 
with  a  fine  suture. 


Fig.   15 


Fig.    15. — The  vein   is   cuffed  back 
over   the   cannula. 


Fig.  16. — The  vein  has  been  cuffed 
back  and  tied,  and  the  artery  is  about 
to  be  drawn  over  the  cuff. 


Fig.   17. The  cuff  of  the  vein  is  tied  near  the   handle  of  the  cannula.     The  cuff  of  ihe   artery   is   tied   in   a 

groove   between   the   middle   ridge   and   the   end   of   the   cannula. 


62  OPERATIVE   SURGERY 

through  which  sutures  applied  to  the  ends  of  the  artery  can  be  carried  to 
aid  in  the  eversion  of  the  artery  over  the  end  of  the  cannula.  E.  C.  Bryan 
and  Euff  devised  a  modification  consisting  of  splitting  the  caniuila  and  hav- 
ing one  side  hinged  so  the  vessel  can  be  laid  in,  instead  of  being  drawn 
through  the  cannula. 

TECHNIC   FOR   DIRECT   TRANSFUSION   OF   BLOOD 

The  operating  tables  or  stretchers  carrying  the  patient,  or  the  recip- 
ient, and  the  donor,  are  placed  in  opposite  directions,  and  in  such  a  position 
that  the  left  arm  of  the  patient  is  in  easy  contact  with  the  left  hand  and 
forearm  of  the  donor.  The  hand  and  forearm  of  the  donor  are  in  contact  with 
the  ulnar  side  of  the  forearm  of  the  recipient.  Between  the  two  operating 
tables  a  small  table  is  placed  on  which  the  arms  of  the  donor  and  the  re- 
cipient rest.  There  is  a  stool  for  the  operator  and  one  on  the  opposite  side  of 
the  small  table  for  the  assistant.  A  good  light  is  essential.  It  is  well  to 
talk  to  the  donor  and  the  recipient  during  the  operation  to  encourage  them 
and  sustain  their  morale.  Local  anesthesia  is  used.  Three  or  four  drops  of 
a  1  to  1000  solution  of  epinephrin  is  added  to  an  ounce  of  one-half  of  one 
per  cent  procaine  solution.  Too  much  epinephrin  makes  bad  healing.  A  re- 
gion about  3  inches  long  over  the  lower  part  of  the  radial  artery  of  the  donor 
is  infiltrated  with  the  local  anesthetic  and  the  radial  artery  is  exposed  through 
an  incision  with  sharp  knife  dissection.  Every  bleeding  point  is  clamped  with 
mosquito  forceps.  It  is  essential  to  have  the  field  as  dry  as  possible.  The 
radial  artery  is  handled  gently  and  the  little  branches  that  come  from  it 
are  doubly  clamped  with  mosquito  forceps,  divided  and  tied  with  fine  black 
silk.  The  radial  artery  is  ligated  with  catgut  at  the  lower  end  of  the  in- 
cision and  at  this  point  dissection  of  the  artery  should  be  quite  close  to  the 
wall  of  the  vessel.  Farther  up,  however,  it  is  better  to  include  as  much  tissue 
around  the  artery  as  possible,  as  this  prevents  somewhat  the  contraction 
of  the  artery  during  dissection  and  decreases  the  chances  of  injuring  the 
arterial  wall  itself.  The  blood  is  stripped  up  with  the  finger  and  thumb  from 
the  radial  at  the  lowest  point  of  the  wound  to  the  highest  point  and  the 
artery  is  clamped  at  the  upper  portion  of  the  wound  with  a  serrefine  or  bull- 
dog forcei3s  whose  pressure  has  been  so  regulated  that  it  will  occlude  the 
artery  without  injuring  its  intima.  This  pressure  can  previously  be  ad- 
justed by  clamping  the  serrefine  on  the  skin  of  the  forearm  of  the  operator 
and  so  changing  the  pressure  of  the  instrument  by  bending  its  spring  that 
it  will  hold  to  the  skin  firmly  without  producing  pain.  The  artery  and 
the  wound  are  then  covered  with  gauze  wrung  out  of  salt  solution,  and  the 
vein  in  the  recipient  is  exposed.  This  is  done  by  grasping  the  anesthetized 
skin  over  a  prominent  vein  just  below  the  elbow  with  a  pair  of  thumb  for- 
ceps, lifting  it  from  the  vein  and  cutting  off  the  apex  of  the  cone  of  skin  that 
is  within  the  grasp  of  the  thumb  forceps.  This  oval  exposure  can  be  ex- 
tended by  a  straight  incision  in  either  direction.     If  possible  a  vein  should 


TRANSFUSION    OF   BLOOD  63 

be  selected  that  has  a  l)ranfh  near  tlie  proposed  point  of  anastomosis.  A 
ligature  is  placed  on  the  vein  at  the  lower  extremity  of  the  wound,  a  mos- 
quito forceps  on  the  branch,  a  serrefine  on  the  vein  at  the  upper  angle  of  the 
wound,  and  the  vein  is  divided. 

The  radial  artery  of  the  donor  is  then  divided  just  above  its  ligature  and, 
if  suturing  is  to  be  done,  the  ends  are  prepared  for  suturing  as  described 
in  Chapter  YI  on  Suturing  Blood  Vessels.  If  a  Crile  cannula  (Fig.  13)  is  to 
be  used  one  or  more  fine  sutures  are  placed  in  the  end  of  the  vein  which 
is  threaded  through  the  cannula,  entering  at  the  handle  end  (Fig.  14). 
It  is  then  brought  out  and  everted  into  a  cuff  by  traction  on  three  or  four  fine 
sutures  or  hooks  in  the  end  of  the  vein  or  by  mosquito  forceps  and  turned 
back  as  far  as  possible  on  the  cannula,  where  it  is  secured  by  a  ligature  of 
silk  near  the  handle  of  the  cannula  (Fig.  15).  It  is  important  to  keep  the 
lumen  of  the  vein  about  the  center  of  the  cannula,  for  if  it  is  drawn  too  much 
to  one  side  the  pressure  of  the  blood  current  may  form  a  pocket  or  valve  and 
greatly  retard  or  stop  the  flow.  The  cannula,  which  is  manipulated  by  hold- 
ing its  handle  with  hemostatic  forceps,  is  transferred  to  the  radial  artery  of 
the  donor,  which  has  been  cut  just  above  the  ligature  and  has  been  seized 
at  three  points  around  its  lumen  with  mosquito  forceps  (Fig.  16).  The 
open  artery  is  drawn  over  the  cannula  and  secured  by  a  ligature  of  silk, 
thus  opposing  the  vascular  endothelium  of  the  donor  to  that  of  the  pa- 
tient (Fig.  17).  The  serrefine  on  the  vein  is  first  removed  and  then  the 
serrefine  on  the  radial  artery.  The  current  is  turned  on  slowly  at  first  and 
stopped  at  intervals  if  the  flow  seems  very  full  or  if  there  is  evidence  of  car- 
diac distress,  such  as  pain  in  the  left  chest,  diificulty  in  breathing,  or  bluish 
color  on  the  part  of  the  patient.  The  donor  should  also  be  carefully  watched, 
his  blood  pressure  taken  at  intervals  and  if  his  color  changes  markedly  and 
suddenly,  transfusion  should  be  at  once  checked  by  application  of  a  serrefine 
on  his  radial  artery.  If  the  donor's  condition  does  not  improve  after  wait- 
ing a  short  time,  the  transfusion  is  discontinued. 

Usually,  with  a  robust  donor,  a  flow  of  about  fifteen  or  twenty  minutes 
is  all  that  is  necessary.  It  is  better,  however,  to  transfuse  as  much  blood 
as  the  patient  and  the  donor  will  stand.  When  the  transfusion  is  discon- 
tinued the  radial  artery  is  ligated  with  catgut  and  the  vein  of  the  patient 
is  similarly  ligated  and  the  connection  containing  the  anastomosis  or  cannula 
is  cut  away.  The  wound  is  closed  with  silk  or  silkworm-gut.  Union  is  likely 
to  be  poor  on  account  of  the  infiltration  with  anesthetic,  the  manipulations 
over  the  wound,  and  the  interference  with,  the  nutrition  of  the  tissues  in  the 
neighborhood  of  the  cut  radial  artery. 

So  far  as  the  eflect  upon  the  patient  is  concerned  direct  transfusion 
either  by  suture  or  by  the  cannula  of  Crile  is,  of  course,  identical.  If  the 
operator  has  had  some  experience  in  suturing  blood  vessels,  suturing  is  prob- 
ably better  than  the  use  of  the  cannula,  for  the  union  between  the  artery 
and   the  vein   can  be   manipulated   or   dilated  by  introducing   through   the 


64 


OPERATIVE    SURGERY 


venous  branch  a  probe,  which  cannot  be  done  when  the  cannula  is  used. 
Then,  too,  if  for  an}-  reason  the  union  is  unsatisfactory  and  has  to  be  cut 
away  and  another  attempt  at  union  made,  much  less  of  the  artei-y  and  vein 
is  sacrificed  by  the  suture  method  than  by  the  cannula  method. 

Some  surgeons  prefer  to  use  the  vein-to-vein  transfusion  instead  of  the 
artery-to-vein.  The  union  is  made  in  a  similar  way  only  a  vein  is  exposed  in 
the  donor  instead  of  the  artery  and  the  distal  end  of  the  vein  of  the  donor 
is  united  to  the  proximal  end  of  the  vein  in  the  patient.  A  light  tourniquet 
to  compress  the  vein  but  not  the  artery  in  the  arm  of  the  donor  is  kept 
in  place  during  the  transfusion  to  promote  the  flow  of  the  venous  blood 
from  the  donor. 

While  the  rich,  oxygenated  blood  from  the  artery  of  the  donor  seems 
more  desirable  for  transfusion  than  the  venous  blood,  there  appears  clini- 
cally to  be  but  little  difference  and  the  danger  of  dilatation  of  the  heart 
in  the  vein-to-vein  transfusion  is  much  less  than  in  the  artery-to-vein  method. 

In  the  semidirect  metJiod  a  tube  or  cannula  is  used  and  the  blood  instead 
of  flowing  directlv  from  the  vascular  endothelium  of  the  donor  to  that  of 


Fig.    18. — Bernheim's    cannula    for   transfusion. 

the  patient  flows  over  an  intermediate  foreign  substance  which  is  the  inner 
wall  of  the  connecting  tube.  This  tube  may  be  made  of  glass,  as  recommended 
by  Brewer.  It  is  tied  into  the  end  of  the  artery  or  vein  in  the  donor  and  into 
the  vein  of  the  recipient  and  the  flow  established  as  after  the  direct  method. 
Care  should  be  taken  to  see  that  the  tube  has  been  boiled  in  paraffin  oil  just 
before  it  is  used  so  as  to  lessen  the  tendency  of  the  blood  to  clot  in  the  can- 
nula. One  spurt  of  blood  is  permitted  from  the  donor  before  the  cannula  is 
applied  to  the  patient's  vein  in  order  to  exclude  the  air. 

The  most  convenient  form  of  cannula,  if  the  semidirect  method  is  chosen, 
is  that  of  Bernheim.  This  consists  of  a  silver  cannula  in  two  parts,  a  male 
and  a  female  part,  which  fit  accurately  into  each  other.  The  ends  terminate 
obliqueh'  and  bluntly,  so  they  may  be  more  readily  inserted  into  the  vessels. 
The  end  of  the  male  half,  which  is  for  the  donor's  artery,  is  slightly  smaller 
than  the  end  of  the  female  half.  It  can  be  used  for  vein-to-vein  trans- 
fusion as  well  as  artery-to-vein   (Fig.   18). 

It  is  used  as  follows: 

The  two  halves  are  disconnected  and  boiled  in  mineral  oil.  The  male  half 
is  inserted  into  the   arterv  of  the   donor   through   a   slit   in   the   side   of  the 


TRANSFITSTON    OF    lU-OOn 


G5 


artery  or  into  the  cut  cud  of  llie  artery,  as  preferrcMl.  Tlie  female  liall:  is 
similarly  inserted  into  tlie  vein  of  the  rceipicMit.  Each  half  is  secured  l)y  a 
liji'atnre.  The  Iavo  Iiahes  are  tilled  witli  salt  soliilioii  to  cxrludc  air,  lillcd 
1o  each  other,  anil  the  hhtod  current  is  tunu'd  on.  This  caniiuhi  method  of 
l>ernheim  is  very  satisfactory.  It  can  be  done  almost  as  easily  as  the  citrate 
method.  One  half  of  the  cannula  may  be  inserted  in  the  donor  in  the  oper- 
ating- room  and  the  donor  taken  to  the  patient's  room  after  the  other  half 
of  the  camnila  has  been  tied  into  the  patient's  vein.       The  donor  is  placed 


Fig.    19. — Kiinpton  and   Brown's   cannula   for  transfusion. 


I'ig.    20. — Kimpton   and    Brown's    cannula    in    horizontal    position,    showing   the    trap    which    prevents    the    en- 
trance of  air   in  the  cannula. 


in  a  comfortable  chair  and  the  two  halves  are  connected.  The  blood  goes 
directly  over  unmixed  with  chemicals  and  if  the  proper  grouping  of  blood  has 
been  made  there  is  never  any  reaction.  The  technic  is  simple.  I  am 
now  using  this  method  almost  exclusively. 

The  indirect  method  of  transfusion  has  in  recent  years  dominated  the 
field.  Without  anticoagulant  mixtures  this  method  is  represented  by  a 
type  of  container  such  as  the  Kimpton  and  Brown,  or  the  Percy  apparatus, 
which  is  coated  with  paraffin,  filled  with  blood  from  the   donor,  and  then 


66  OPERATIVE    SURGERY 

emptied  into  the  vein  of  the  patient.  (Figs.  19  and  20.)  Another  indirect 
method  consists  in  the  aspiration  of  blood  from  the  vein  of  the  donor  into  a 
syringe  Avhieh  is  immediately  emptied  into  the  vein  of  the  patient.  This 
is  called  the  method  of  Lindeman,  who  inserts  a  small  cannula  in  the  vein 
of  the  donor  and  a  similar  one  into  the  vein  of  the  recipient.  Blood  is  rapidly 
drawn  out  by  the  syringe  from  the  cannula  in  the  donor  and  quickly  emptied 
into  the  vein  of  the  recipient.  This  requires  skillful  assistance  and  a  series 
of  syringes,  Avhich  must  be  cleaned  with  salt  solution  after  each  emptying. 

There  are  many  theoretical  objections  to  indirect  methods  because  very 
little  is  known  of  the  actual  physiologic  changes  in  the  blood.  Even  so 
gross  a  change  as  clotting  has  not  been  thoroughly  explained.  It  seems  prob- 
able then,  that  when  blood  is  withdrawn  from  contact  with  its  vascular  en- 
dothelium and,  particularly,  when  it  is  mixed  Avith  foreign  chemicals,  changes 
occur,  which,  though  too  fine  to  j)ermit  of  chemical  detection,  alter  the  bio- 
logic function  of  the  blood.  That  some  such  changes  do  occur  is  evidenced  b}^ 
the  fact  that  when  citrated  blood  is  used  the  coagulation  time  of  the  pa- 
tient's blood  is  markedly  decreased.  As  coagulation  is  dependent  upon 
certain  definite  chemical  changes  and  as  these  in  turn  require  the  presence  of 
some  materials  which  result  from  injured  cells,  it  is  evident  that  destruc- 
tion or  injury  of  cells  occurs,  which  therebj^  releases  thrombokinase,  or  pro- 
thrombin, that  is  essential  to  the  fibrin  ferment  of  coagulation.  This  element 
of  fibrin  ferment  is  always  derived  from  injured  cells,  probably  chiefly  from 
the  platelets  of  blood.  However,  as  the  important  constituents  of  transfused 
blood  seem  to  be  preserved  intact  in  the  citrate  method  and  as  clinically  the 
citrate  method  gives  about  the  same  results  as  other  methods  in  restoring  the 
hemoglobin  of  the  recipient,  theoretical  objections  should  not  militate  too 
greatly  against  the  very  simple  method  of  citrate  transfusion  of  blood,  as 
devised  by  Lewisohn.    The  marked  reaction  is  the  chief  objection. 

The  technic  of  introducing  this  blood  is  identical  with  that  of  intravenous 
infusions  of  salt  solution  or  Locke's  solution.  Unless  the  hemoglobin  is  too 
low  or  the  condition  of  the  patient  too  desperate,  intravenous  infusion  of 
Locke's  solution  should  be  applied  before  resorting  to  transfusion. 

The  recipient  should  be  prepared  for  the  blood  before  the  blood  is  drawn 
from  the  donor.  The  patient  needing  the  transfusion  is  usually  so  anemic 
and  the  veins  are  so  collapsed  that  it  is  best  to  insert  a  cannula  into  his  vein 
through  a  short  incision.  This  is  made  under  local  anesthesia,  lifting  with 
thumb  forceps  the  skin  over  a  vein  near  the  elbow  and  cutting  away  the 
apex  of  this  elevated  cone  of  skin.  (Fig.  21.)  This  leaves  an  oval  wound. 
A  ligature  is  applied  around  the  vein  at  the  lowest  portion  of  the  wound 
and  tied.  Another  ligature  is  placed  around  the  vein  at  the  upper  portion 
of  the  wound  but  is  left  untied.  The  wall  of  the  vein  is  grasped  with  a  small 
thumb  forceps  or  mosquito  forceps  and  incised  obliquely.  (Fig.  22.)  The 
intravenous  cannula  or,  in  an  emergency,  a  medicine  dropper  which  is  at- 
tached by  a  rubber  tube  to  a  glass  container  or  to  an  irrigating  can  contain- 
ing about   100  c.c.   of  Locke's   solution,   is  then  inserted   into   this   opening 


TRANSFUSION    OF    BLOOD 


67 


in  the  vein  wliile  the  sohition  is  flowing.  The  ligature  at  the  upper  end  of  the 
wound,  wliieh  was  thrown  around  the  vein  hut  not  tied,  is  tiglitened  around  the 
cannuhi.  The  cannnhi  is  inserted,  flowing,  to  avoid  the  introduction  of  air.  Some- 
times when  tlie  insertion  is  a  little  difficult  the  opening  in  the  vein  can  ])e  made 


Fig.  21. — The  skin  is  caught  up   over  a  prominent  vein   in  front   of  the   elbovv    and   the   apex   of   the   skin   is 

cut  awav   with   scissors. 


Fig.   22.— A  ligature   has  been  tied   on  the   distal   side   of  the   vein,   another   ligature   placed   but    not   tied   on 
the  proximal  side,  and  the  vein  has  been  opened  with  an  oblique  incision. 

more  conspicuous  by  inserting  a  closed  mosquito  forceps  and  opening  the  forceps, 
or  by  catching  the  edges  of  the  opening  with  two  mosquito  forceps  and  pulling 
the  wound  open,  or  by  inserting  a  grooved  director  and  pushing  the  cannula 
along  the  grooved  director.     Sometimes  one  of  these  manipulations  is  easier 


68  OPERATIVE    SURGERY 

than  another  and  sometimes  none  of  them  is  required.  It  is  always  well, 
however,  to  be  prepared  for  any  one  of  them.  After  about  50  c.c.  of  Locke's 
solution  have  run  into  the  vein  the  citrated  blood  is  poured  into  the  container 
and  the  flow  continued.  If  the  flow  is  too  rapid  it  is  checked  at  intervals. 
When  only  25  c.c.  remain  in  the  container,  more  Locke's  solution  is  poured 
in  so  that  all  of  the  citrated  blood  will  flow  into  the  vein  Avithout  the 
danger  of  the  entrance  of  air.  If  the  amount  of  blood  is  not  sufficient  more 
blood  can  be  obtained  in  a  similar  way  and  introduced  through  the  same 
cannula.    As  a  rule,  however,  500  c.c.  of  citrated  blood  are  sufficient. 

In  obtaining  blood  for  the  citrate  method  a  cannula  within  a  cannula  is 
introduced  into  the  donor's  vein,  Avhich  is  distended  by  applying  a  tourniquet 
lightly  to  the  arm.  There  are  special  cannulas  for  this  purpose  on  the  market, 
which  consist  of  a  very  small  cannula  containing  a  wire  that  does  not  reach  the 
end  of  the  cannula.  This  is  fitted  into  a  large  cannula.  After  introduction,  the 
wire  is  withdrawn  and  if  the  blood  flows  through  the  small  cannula,  this  is 
withdrawn,  leaving  the  larger  cannula  in  position.  Usually  the  median  cephalic 
vein  in  the  region  of  the  elbow  is  selected.  The  large  cannula  must  be  of  suffi- 
cient caliber  to  permit  the  blood  to  flow  freely  and  not  to  drop.  If  it  drops 
from  the  cannula  it  is  likely  to  clot. 

Sometimes  the  donor's  vein,  if  not  large,  is  transfixed  with  a  straight 
round  needle  to  hold  it  steady.  If  there  is  difficulty  in  introducing  the 
cannula  into  the  donor  a  short  incision  may  be  made  and  the  vein  exposed. 
If  the  vein  has  been  rendered  sufficiently  prominent  by  cording  and  the 
cannula  has  been  introduced  obliquely  in  the  general  course  of  the  vein, 
usually  there  is  no  trouble  in  securing  a  good  flow,  which  can  be  increased 
by  having  the  donor  work  his  fingers  or  by  adjusting  the  tourniquet. 

The  blood  is  collected  into  a  graduated  glass  jar  containing  50  c.c.  of 
2  per  cent  citrate  of  sodium  and  1  per  cent  sodium  chloride  solution.  This  is 
sufficient  for  450  c.c.  of  blood  which  will  make  a  total  bulk  of  500  c.c.  of  citrated 
blood.  The  inside  of  the  graduate  is  thoroughly  moistened  with  citrate  solution, 
so  that  when  the  blood  touches  its  side  it  will  not  coagulate.  The  flow  of  the 
stream  is  directed  to  the  center  of  the  graduate  as  nearly  as  possible  and  the 
blood  is  thoroughly  mixed  as  it  flows,  by  stirring  it  gently  with  a  glass  rod. 
Care  should  be  taken  to  draw  no  more  than  450  c.c.  of  blood  to  the  50  c.c. 
of  2  per  cent  solution  of  citrate  of  sodium,  otherwise  coagulation  will  take 
place.  To  be  on  the  safe  side  it  is  better  to  draw  a  little  less  than  450  c.c.  of 
blood.  It  will  also  be  found  that  if  the  donor  is  excited  the  blood  ma}^  have 
a  greater  tendency  than  normal  to  coagulate  and  an  additional  allowance  of 
citrate  solution  should  be  made. 

The  chief  clinical  objection  to  the  citrate  method  is  that  there  are  more  chills 
than  after  other  methods.  Lewisohn  thinks  that  about  20  per  cent  of  citrate  trans- 
fusions are  followed  by  chills.  Others  find  a  larger  percentage  of  reac- 
tions. It  is,  of  course,  taken  for  granted  that  the  proper  tests  have  been 
made  for  agglutination  and  hemolysis  between  the  donor  and  the  recipient. 


CHAPTER  VI 

SUTURING  BLOOD  VESSELS 

The  field  of  blood  vessel  suturing  has  eontracted  considerably  in  recent 
years.  The  indications  for  suturing  wounded  blood  vessels  have  been  con- 
sidered as  follows: 

1.  AVounded  blood  vessels  where  direct  suture  instead  of  a  ligature  is 
used. 

2.  Excision  of  malignant  tumors  that  have  heretofore  been  considered 
inoperable  because  of  involvement  of  a  large  blood  vessel. 

3.  Aneurisms  in  which  the  collateral  circulation  would  not  be  sufficient 
to  sustain  the  nutrition  of  the  limb  if  the  vessel  is  tied. 

4.  Transfusion  of  blood. 

5.  Reversal  of  the  circulation. 

(1)  In  the  treatment  of  a  wounded  blood  vessel,  particularly  a  vein, 
Avith  a  lateral  wound,  direct  suture  is  indicated  instead  of  a  ligature.  It 
has  been  found,  however,  as  an  experience  of  the  Avar,  that  in  young  men, 
Avho  Avere  previously  healthy,  and  in  whom  the  loss  of  blood  Avas  not 
too  great,  ligation  of  the  ends  of  a  large  Avounded  vessel  close  to  the  in- 
jury is,  in  the  great  majority  of  cases,  satisfactory.  The  objections  to  usnig 
blood  vessel  suturing  in  military  surgery  are  that  in  many  cases  it  seems, 
to  be  unnecessary,  and  usually,  Avhen  indicated,  the  exigencies  of  the  situa- 
tion are  such  as  to  make  the  teehnic  of  blood  vessel  suturing  difficult  or  im- 
possible to  perform.  Undoubtedly,  in  traumatic  surgery  Avhere  cases  can  be 
treated  in  Avell  equipped  hospitals  and  by  surgeons  Avho  have  acquired  the 
proper  teehnic,  there  Avill  be  occasional  instances  in  Avhich  suturing  of  in- 
jured blood  vessels  will  be  the  best  treatment  for  the  patient. 

(2)  In  excision  of  malignant  tumors  involving  large  vessels  the  indi- 
cations for  removing  the  vessels  are  not  so  clear  as  it  Avould  appear.  If  the 
vessel  has  been  gradually  pressed  upon  by  the  extension  of  the  groAvth  and  its 
circulation  gradually  decreased,  collateral  circulation  Avill  have  formed  and 
the  involved  blood  vessel  can  be  excised  AA^th  much  less  danger  of  gangrene 
than  if  the  vessel  had  been  excised  before  the  collateral  circulation  had  l^een 
developed.  This  is  the  same  principle  that  is  taken  advantage  of  by  Halsted 
and  by  Matas  in  the  gradual  occlusion  of  large  vessels  by  the  use  of  mallea- 
ble metal  bands,  Avhich  can  be  so  adjusted  as  to  produce  a  greatly  decreased 
flow  through  the  vessel.  But  if  the  tissues  around  the  vessel  are  infiltrated 
and  the  vessel  itself  is  not  materially  pressed  upon,  it  Avould  be  safer  to  ex- 
cise the  artery  and  then  suture  betAveen  the  divided  ends  a  segment  of  vein, 

(3)  In  the  treatment  of  aneurisms  the  endo-aneurismorrhaphy  of  Matas 

69 


70  OPERATIVE    SURGERY 

can  be  applied  in  almost  all  aneurisms  in  which  the  circulation  can  be  tem- 
porarily arrested.  In  other  instances,  ligation  according  to  some  of  the 
standard  technics  or  the  gradual  occlusion  of  the  vessels  by  a  malleable 
band,  is  usually  satisfactory.  There  may,  however,  be  occasional  instances 
in  which  on  account  of  enfeebled  collateral  circulation,  excision  of  the  aneur- 
ism and  suturing  a  segment  of  vein  between  the  divided  ends  of  the  artery 
is  indicated. 

(4)  In  transfusion  of  blood,  the  ideal  method  would  be  to  transfer  the 
blood  from  the  donor  to  the  patient  over  a  continuous  surface  of  vascular 
endothelium.  The  objections  to  this  are  the  difficulty  of  the  technie,  the  dan- 
ger of  dilatation  of  the  heart,  and  the  inability  to  measure  the  dosage  of 
blood.  The  indirect  method  of  transfusion  by  citrate  of  sodium,  which  ap- 
parently renders  the  blood  incoagulable  by  combining  with  the  calcium  ele- 
ments in  the  plasma,  is  simple,  and  the  cannula  of  Bernheim  seems  to  be  clini- 
cally so  effective,  that  there  is  but  little  place  for  suturing  blood  vessels  in  trans- 
fusion of  blood. 

(5)  The  so-called  reversal  of  the  circulation  for  threatened  gangrene 
has  been  proved  to  be  a  fallacy  and  there  is  no  indication  here  for  suturing 
vessels. 

There  are,  however,  occasional  instances  in  which  blood  vessels  should 
be  sutured  or  a  segment  of  vein  transplanted  and  it  w^ould  be  well  for  the 
surgeon  to  acquire,  knowledge  of  this  technie  which  can  only  be  gained  by  ex- 
perimental work.  He  will  find  too,  that  it  improves  his  general  surgical 
technie  and  teaches  gentleness  in  handling  tissues. 

The  chief  difficulty  to  overcome  in  suturing  blood  vessels  is  occlusion  by  clot- 
ting, and  the  whole  technie  is  intended  to  prevent  an  excessive  amount  of  clotting 
while  at  the  same  time  repairing  the  walls  of  the  vessel  in  such  a  manner  that  they 
will  withstand  the  normal  blood  pressure.  If  a  vessel  becomes  occluded  by  clot- 
ting at  the  site  of  operation  it  might  as  well  have  been  ligated.  Indeed,  a  ligature 
would  be  safer  because  a  part  of  the  thrombus  at  the  site  of  clotting  in  a 
sutured  vessel  may  become  dislodged  and  interfere  with  collateral  circulation. 

In  order  to  appreciate  the  necessity  for  certain  steps  in  suturing  blood 
vessels,  it  is  necessary  briefly  to  review  the  physiology  of  thrombus  formation. 

The  physiology  of  thrombus  formation  is  still  somewhat  vague,  though 
certain  general  reactions  are  acknowledged  by  all  physiologists.  The  forma- 
tion of  a  clot  or  thrombus  is  due  to  the  action  of  a  material  called  fibrin  fer- 
ment, or  thrombin,  on  fibrinogen.  Fibrinogen  exists  normally  in  the  blood 
plasma.  Fibrin  ferment  is  built  up  of  various  substances  and  is  formed 
from  the  action  of  a  thrombo-plastic  substance,  called  by  some  thrombokinase, 
upon  thrombogen  in  the  presence  of  a  solution  of  calcium  salts.  Thrombo- 
kinase is  not  a  true  kinase  in  the  sense  of  acting  solely  as  a  ferment,  for  it 
is  used  up  in  the  process  of  clotting.  Thrombokinase  is  the  key  to  the  situa- 
tion, and  whether  it  acts  directly,  or  indirectly,  as  Howell  claims,  by  com- 
bining with  antithrombin  in  the  blood  and  thus  liberating  prothrombin  (throm- 
bogen), it  nevertheless  is  essential  to  clotting  and  to  a  large  extent  regu- 


SUTURING    BLOOD   VESSELS 


71 


lates  the  amount  of  thrombus  formed.  Thromljolviiiase  is  supposed  to  be 
present  in  all  tissues  of  the  body  and  also  comes  from  disorganized  blood 
corpuscles,  particularly  the  platelets.  It  seems  abundant  in  the  adventitia  of 
blood  vessels,  probably  due  to  the  fact  that  this  coat  of  a  blood  vessel  is 
loose  and  areolar,  and  entangles  the  platelets  or  blood  cells  in  its  sub- 
stance when  bleeding  occurs.  This  seems  a  provision  by  which  nature  at- 
tempts to  stop  hemorrhage. 

The  practical  bearing  of  these  facts  upon  blood  vessel  surgery  is  evident, 
for  thrombokinase  can  only  be  liberated  from  injured  cells.  As  the  amount 
of  clotting  is  directly  proportionate  to  the  amount  of  thrombokinase,  it  is  read- 
ily seen  that  any  undue  injury  to  blood  vessels  by  rough  handling,  or  by 
drying  of  the  endothelial  cells  of  the  intima,  or  by  the  presence  of  too  much 
foreign  substance  in  the  lumen,  or  by  chemical  or  bacterial  injuries,  will 
result  in  the  liberation  of  so  much  thrombokinase  that  excessive  thrombus 


Fig.   23. — The  three  tractor  sutures  are   placed.      (Carrel.) 

is  formed  and  the  vessel  is  occluded.  Even  the  most  successful  suturing  of 
blood  vessels  is  accompanied  by  some  clotting;  but  a  limited  amount  is  es- 
sential, as  it  serves  to  fill  the  punctures  from  the  needle  holes  and  to  bridge 
over  the  line  of  contact.  In  successful  vessel  suturing,  however,  the  injury 
is  so  slight  that  very  little  thrombokinase  is  released  and  consequently  only 
a  small  amount  of  thrombus  is  formed,  just  enough  to  plug  the  punctures 
made  by  the  needle  and  not  enough  to  obstruct  the  lumen. 

We  recognize,  then,  as  the  principles  for  successful  blood  vessel  suturing 
that  a  continuous  surface  of  vascular  endothelium  must  line  the  lumen  of 
the  blood  vessels  and  that  as  little  injury  as  possible  must  be  done  this  en- 
dothelium. 

Probably  the  best  known  method  of  suturing  blood  vessels  was  published 
by  Carrel,  in  1902.  It  differs  in  no  essential  particular  from  the  work  of 
others,  but  is  a  combination  of  the  best  features  of  other  work.     The  results 


72 


OPERATIVE    SURGERY 


obtained  were  much  better  than  those  secured  by  any  one  else.  He  used 
very  fine,  No.  16,  round,  straight  needles,  threaded  with  fine  silk  impregnated 
with  vaseline.  The  adventitia  is  thoroughly  removed  and  the  ends  of  the 
artery  are  washed  out  with  salt  solution,  or  Kinger's  solution.  The  ends  of  the 
A^essels  are  then  united  by  three  traction  sutures  inserted  around  the  artery 
at  equidistant  points  (Fig.  23).  Traction  on  the  sutures  converts  the  circum- 
ference of  the  artery  into  a  triangle,  approximates  the  intima,  and  facilitates 
the  suturing.  (Fig.  24).  The  operator  holds  one  traction  suture,  the  assist- 
ant holds  another,  and  the  third  is  caught  in  a  small  hemostatic  forceps,  so  as 
to  pull  the  artery  away  from  the  region  that  is  being  sutured.  After  sutur- 
ing one-third  Avith  a  continuous  overhand  stitch  the  operator  takes  the  traction 
suture  held  by  the  assistant,  the  assistant  takes  the  one  to  which  the  hemostat 


Fig.  24. — The  three  sutures  are  tied  and  the   upper  third  is  ready  for  suturing.      (Carrel.) 

was  fastened,  and  the  hemostat  is  placed  upon  the  traction  suture  that  the 
operator  originally  held.  (Fig.  25).  After  the  second  third  is  finished  the 
traction  sutures  are  again  changed,  the  operator  taking  the  one  held  by  the 
assistant,  who  makes  tension  on  the  suture  that  Avas  clamped  by  the  hemostat 
and  the  hemostat  is  placed  on  the  suture  just  released  1)y  the  operator.  The 
last  third  is  sutured  and  the  blood  current  is  turned  on  gently.  (Fig.  26.) 
Slight  pressure  usually  stops  the  oozing  from  the  needle  holes,  and  then  the 
full  force  of  the  blo(jd  stream  is  released. 

The  objections  to  the  method  of  Carrel  are:  (1)  it  is  complicated,  diffi- 
cult and  requires  trained  assistants;  (2)  the  sutures  are  placed  under  A-ary- 
ing  conditions  of  pressure  at  different  points  along  the  line  and  the  trans- 
ference of  the  guy  or  traction  sutures  during  operation  is  confusing;  (3) 
a  A'ery  small  surface  of  the  Avascular  endothelium  is  approximated.  In  an 
effort   to   overcome   these    difficulties   I   have   devised   a    technic    that    in   my 


SUTURING    BLOOD   VESSELS 


73 


hands  lias  proved  satisfactory  and  seems  to  meet  the  objeetions  that  have  been 
stated. 

In  sntnrinp:  bh)od  vessels  it  is  essential  to  have  the  least  possible  trauma 


Fig.    25. — The   suturing   of   the    upper   third    is    completed.      (Carrel.) 


Fig.  26. — The  suturing  has  been  completed  and  the  current  of  blood  has  been  turned  on.      (Carrel.) 

and  irritation  to  vascular  endothelium.  In  order  to  avoid  drying  of  the 
endothelium  and  to  prevent  contamination  of  the  sutured  surfaces  with  juices 
from  the  cut  ends  of  the  artery,  which  contain  thrombokinase,  it  has  been 


74  OPERATIVE    SURGERY 

customary  to  smear  the  exposed  ends  of  the  vessel  with  vaseline  or  with 
paraffin  oil,  and  the  stitches  are  impregnated  in  this  material. 

Cubbins  and  Abt^  have  shown  that  A'-aseline,  alboline  and  lanolin  are  irri- 
tating to  the  peritoneum,  as  is  paraiftn  oil,  though  in  a  lesser  degree.  These 
substances  appear  to  promote  adhesions  instead  of  preventing  them.  They 
show  that  olive  oil,  Mdiile  not  preventing  adhesions,  has  no  irritating  effect  and 
is  absorbed.  If  this  is  true  of  the  peritoneal  endothelium,  it  is  probably  also  true 
of  vascular  endothelium.  Besides  the  irritating  effect  which  would  follow  clotting, 
these  substances  act  as  foreign  bodies,  do  not  dissolve  in  the  blood  stream  and 
may  cover  injured  cells  or  thrombokinase  which  will  later  cause  local  thrombus 
formation. 

To  avoid  these  objections  I  have  abandoned  the  use  of  vaseline  in  blood 
vessel  suturing,  except  that  the  arterial  needles  and  threads  are  boiled  in 
vaseline.  This  seems  necessary  for  the  arterial  sutures  are  so  fine  that 
they  will  not  run  smoothly  through  the  tissues  unless  lubricated  and  vase- 
line is  an  excellent  lubricant  for  this  purpose.  Olive  oil  is  a  poor  lubricant. 
The  small  amount  of  vaseline  that  adheres  to  the  thread  is  largely  covered  by  the 
approximated  vessel  walls  when  a  double  mattress  or  cobbler's  stitch  is  used  and 
so  very  little  or  none  of  it  appears  in  the  lumen  of  the  vessel. 

The  importance  of  presenting  to  the  lumen  of  the  vessel  a  continuous 
surface  of  vascular  endothelium,  is  appreciated  when  we  recall  what  has 
been  learned  in  a  somewhat  coarser  fashion  in  intestinal  suturing,  where 
it  is  a  well  recognized  principle,  as  it  is  in  blood  vessel  suturing,  that  the 
endothelial  surfaces  must  be  approximated  accurately.  In  the  bowel,  the  endo- 
thelium is  on  the  outside  and  it  is  necessary  to  turn  in  a  small  flange  or  shelf 
to  secure  accurate  apposition  of  the  peritoneal  endothelium.  In  blood  ves- 
sels the  endothelium  is  on  the  inside  and  it  is  essential  to  turn  out  a  flange 
in  order  to  approximate  the  endothelial  lining  of  the  blood  vessel.  The 
usual  method  of  suturing  blood  vessels  consists  in  first  placing  three  guy 
sutures  and  then  whipping  the  edges  of  the  vessel  together  by  an  overhand 
stitch.  This  necessarily  cannot  approximate  the  endothelial  surface  on  the 
inside  as  accurately  as  would  a  mattress  stitch  which  turns  out  a  flange  and 
compels  the  apposition  of  the  intima.  No  one  would  think  of  suturing  a 
bowel  in  a  similar  manner  and  claim  that  the  peritoneum  could  be  accurately 
brought  together  by  merely  whipping  over  the  margins  of  the  bowel  wound 
as  in  suturing  skin.  If  this  cannot  be  done  in  intestinal  surgery,  the  same 
thing  holds  equally  in  blood  vessel  surgery. 

The  presence  of  foreign  substances  in  the  lumen  of  a  blood  vessel  promotes 
clotting.  Some  substances  favor  clotting  more  than  others.  Other  things 
being  equal,  however,  the  larger  the  amount  of  foreign  substance  or  raw 
surface  in  the  blood  vessel,  the  greater  the  likelihood  of  extensive  clotting. 
A  mattress  suture  that  turns  out  a  flange  not  only  approximates  the  intima 
more  accurately  but  leaves  almost  no  thread  exposed  in  the  lumen;  whereas 
the  continuous  overhand  stitch  leaves  a  considerable  amount  of  thread  in  the 


iSurg.   Gynec.   &   Obst.,   May,    1916,   pp.   571-579. 


SUTURING    BLOOD   VESSELS 


75 


lumen.  This  is  readily  seen  from  the  accompanying  cut  (Figs.  27  and  28) 
which  is  reproduced  from  (iuthrie's  work  on  blood  vessel  surgery  and  shows 
the  inside  of  the  vessel  soon  after  being  sutured  by  the  usual  method.  The 
mattress  suture  which  is  parallel  to  the  wound  also  secures  a  better  hold 
upon  the  tissues  than  the  overhand  stitch  which  is  at  right  angles  to  the 
wound,  and  the  mattress  stitch  is,  consequently,  less  liable  to  cut  (Figs.  27 
and  29).  This  is  due  to  the  fact  that  in  the  mattress  suture  the  tension  is 
more  equally  distributed  along  the  whole  loop  of  the  stitch,  whereas  in  the 
overhand  stitch  the  tension  is  concentrated  at  one  point,  that  is,  at  the  end  of 
the  suture  farthest  from  the  wound.  This  fact  has  been  brought  out  by 
Lexer,  who  excised  an  aneurism  and  sutured  a  piece  of  the  saphenous  vein 
into  the  defect.  He  said:^  "The  wall  of  the  artery  markedly  changed  by 
arteriosclerosis  allowed  the  threads  of  the  running  suture  of  Carrel  to  cut 
through.      On   the   other   hand,    the    continuous   protruding   mattress    suture 


Fig.  28. 


Fig.   29. 


Fig.  27. 

Fig.  27. — This  drawing,  reproduced  from  Guthrie,  shows  the  lumen  of  a  blood  vessel  immediately 
after  it  has  been  sutured  by  the  method  of  Carrel.     Note  large  amount  of  thread  exposed  in  the  lumen. 

Fig.  28. — ^This  drawing,  also  from  Guthrie,  shows  the  lumen  of  a  blood  vessel  several  weeks  after 
successful  suture.  The  stitches  have  been  covered  by  endothelium,  which  is  still  transparent.  The  older 
the  specimen,  the  thicker  and  more  opaque  is  the  covering  over  the  sutures,  until  after  several  months  the 
stitches  are  completely  hidden.  This  seems  true  of  any  method  of  suturing,  but  it  is  the  first  few  days 
after  suturing  that  the  amount  of  thread  exposed  in  the  lumen  is  important.  Sutures  seem  to  work  away 
from  endothelial  surfaces  toward  the  lumen  in  the  intestines  and  toward  the  surface  in  blood  vessels. 

Fig.  29. — This  drawing  shows  the  eversion  produced  by  the  double  mattress  stitch  and  the  consequent 
absence  of  any  raw  surfaces  in  the  lumen  of  the  vessel.  Note  the  small  amount  of  thread  exposed  to  the 
blood  current,  as  compared  with  Fig.  27,  and  the  strong  grip  that  the  loop  of  the  mattress  stitch  has  on 
the  tissues. 

gave  very  good  service;  the  thread  not  only  held  well  but  also  prevented 
hemorrhage." 

Asepsis  in  blood  vessel  suturing  should  be  as  nearly  perfect  as  possible, 
just  as  it  should  be  in  abdominal  surgery,  brain  surgery  or  bone  surgery. 
If  the  tissues  around  the  blood  vessels  are  infected  no  suturing  can  be  expected  to 
be  satisfactory.  Yet  even  in  the  presence  of  infection  blood  vessel  suturing  is  not 
invariably  a  failure,  as  I  have  one  successfully  sutured  femoral  artery  in  a 


=^Lexer:  Jour.  Am.  Med.  Assn.,  May  10,  1913,  p.  1474. 


76  OPERATIVE    SURGERY 

dog  in  which  the  tissues  around  the  vessel  suppurated  for  several  weeks. 
As  a  rule,  however,  infection  will  result  in  failure  and  the  proper  aseptic 
technic  should  be  insisted  upon.  Particularly  should  dust  be  avoided.  The 
operator  should  wear  a  mask  over  his  mouth  and  the  floor  of  the  operating 


Fig.  30.^^Special  instruments  used  in  the  author's  method  of  end-to-end  suturiuR  of  blood  vessels. 
On  the  left  is^the  arterial  suture  staff,  and  next  to  it  is  a  small  thumb  forceps  called  '"frog"  forceps.  On 
the  right  is  a  "mosquito"  hemostatic  forceps,  and  ne.xt  to  it  two  scrrefines,   or  "bulldog"  forceps. 

room  should  preferably  be  moist.  In  laboratory  work  the  floor  should  be 
flushed  Avith  water  an  hour  or  two  before  operating.  The  manner  of  hand- 
ling tissues  is  most  important,  for  gentleness  is  an  absolute  essential.  No 
matter  Iioav  careful  the  aseptic  technic,  good  results  cannot  be  secured  by 


SUTURING    151  .OOn    Vi:SSKTiS 


77 


one  who  nsos  tlio  sniiic  indlinds  of  luiiullino;  tissue  in  l)lood  vessel  surgery 
as  would  be  adopted  in  ))()iie  surgery.  Tlie  vascular  endothelium  must  not 
be  permitted  to  di'y,  or  shouUl  it  l)e  touched  with  any  instrument. 

As  for  instruuuMits,  1  use  No.  K)  straig'ht  needles  threaded  with  00000 
twist  black  silk.  They  are  threaded  with  silk  about  fourteen  inches  long 
and  a  single  knot  is  tied  on  the  eye  of  the  needle  to  prevent  it  becoming 
unthreaded.  The  short  end  should  be  cut  within  half  an  inch  of  the  needle 
to  avoid  unnecessary  loose  ends  dangling  about.  Five  of  these  threaded 
needles  are  run  through  a  piece  of  gauze  of  double  thickness  about  two  inches 
Avide  and  as  long  as  the  thread.     This  gauze  is  then  placed  in  a  small  can  or 


Fig.  31. — The  artery  is  exposed,  blood  stripped  Fig.     32.— The    artery    has    been     severed    by     sharp 

from   it,    and   serrefine  clamps   are  placed.      Plain  scissors  and  the  adventitia  which  curls  over  the  ends  of 

gauze  is  under  the  artery.  The  dotted  line  shows  the  artery  is  pulled  down  and  cut  away  with  scissors, 
the    proposed    incision. 

ointment  jar  that  is  one-half  full  of  white  vaseline,  and  the  jar  is  closed  and 
sterilized.  The  needles  are  not  removed  until  they  are  to  be  used,  when 
they  are  taken  from  the  gauze. 

To  place  the  cobbler's  stitch  satisfactorily,  it  is  necessary  to  have  an 
instrument  called  ''an  arterial  suture  staff"  which  I  have  devised  in  an 
effort  to  simplify  the  technic.  This  instrument  (Fig.  30)  consists  of  a  small 
steel  shaft  which  curves  at  one  extremity  into  a  shorter  shaft.  The  long  shaft, 
or  handle,  is  six  inches  long,  and  the  short  shaft  is  one  and  three  quarter 
inches  long  and  is  placed  at  an  angle  of  about  sixty  degrees  to  the  long 


78 


OPERATIVE    SURGERY 


shaft.  The  curved  portion  is  flattened  to  form  a  spring.  There  are  five 
buttons;  one  on  the  main  shaft  as  close  as  possible  to  the  curved  spring,  one 
at  the  extremity  of  the  short  shaft,  one  just  below  this,  and  two  on  the  main 
shaft  at  points  about  opposite  the  buttons  on  the  short  shaft.  These  but- 
tons hug  the  instrument  closely  and  are  so  constructed  that  the  guy  sutures 
are  securely  held  by  simply  wrapping  them  twice  around  the  buttons.  In 
order  to  occlude  the  vessel,  either  a  rubber  covered  Crile  clamp  is  used, 
or  the  ordinary  serrefine,  or  bulldog  clamp,  uncovered,  which  has  a  spring- 
so   weakened  that   the   clamp   can   grasp   the   skin   of   the   forearm   without 


Fig.  33. — The  thumb  and  finger  of  the  left  hand 
grasp  the  end  of  the  artery  after  the  adventitia  has 
been  cut  away,   and   olive   oil   is   dropped   on   the  artery. 


Fig.  34. — The  first  suture  has  been  placed 
and  is  wrapped  around  the  lowest  button  on  the 
long  shaft  and  cut  short. 


pain.  The  inside  of  the  blood  vessel  should  never  be  caught  with  forceps, 
though  sometimes  it  is  necessary  to  grasp  the  outside.  For  this  .purpose  the 
ordinary  thumb  forceps  called  "frog  forceps"  by  the  instrument  dealers 
and  sold  for  biologic  dissection  are  excellent.  Several  mosquito  hemo- 
static forceps  are  needed  (Fig.  30).  Aside  from  these  special  instruments, 
the  usual  instruments  may  be  employed.  The  knife  and  scissors  should  be 
sharp. 

The  vessel  is  exposed,  keeping  the  tissues  as  dry  as  possible.  A  serrefine 
is  placed  on  the  portion  of  the  vessel  nearest  the  heart,  and  the  vessel  is 
gently  grasped  between  the  thumb  and  finger  and  stripped  of  blood  to  the 


SUTURING    BLOOD   VESSELS 


79 


other  angle  of  the  m'oiukI,  -where  another  serrefine  is  ])hiee(l.  This  leaves  the 
artery  dry  and  flat  like  a  ribbon.  Dry  gauze  or  ganze  wet  with  salt  solution  now 
is  placed  beneath  the  vessel  (Fig.  31),  after  stopping  all  bleeding  in  the 
wound,  and  the  artery  is  divided  with  one  stroke  of  sharp  scissors.  The  fingers 
are  wiped  free  of  blood  and  moisture  on  a  dry  towel  and  the  left  finger  and 
thumb  grasp  one  of  the  ends  of  the  artery  firmly  and  pull  the  adventitia  over 
its  cut  end.  The  adventitia  is  cut  off  on  a  level  with  the  rest  of  the  artery 
(Fig.  32).  It  then  retracts,  leaving  the  middle  and  inner  coats  exposed.  Any 
remaining  clots  in  the  vessel  are  stripped  out  with  the  thumb  and  finger 
and  the  end  is  held  firmly  between  the  thumb  and  finger  of  the  left  hand  and 


I  **-_ 


Fig  35  — The  handle  of  the  arterial  suture  slaff  is  depressed  away  from  the  operator  and  the  short 
shaft  may  be  turned  flat  and  caught  so  as  to  manipulate  the  ends  of  the  artery  into  a  convenient  position 
for  inserting  the  second  suture.  The  second  suture  is  inserted,  tied,  and  wrapped  around  one  ot  the 
upper  buttons   on   the   long  shaft. 

sponged  with  dry  gauze.  As  the  artery  is  collapsed  and  its  end  held  between 
the  finger  and  thumb  the  gauze  cannot  touch  the  intima,  but  merely  ^^dpes 
the  wounded  portion  and  so  removes  any  excess  of  thrombokinase.  Olive 
oil  is  dropped  on  the  end  of  the  vessel  with  a  medicine  dropper  (Fig. 
33).  This  washes  away  the  tissue  juice  containing  thrombokinase,  and  pre- 
vents drying  of  the  intima.^ 

All  of  these  manipulations  are  done  rapidly  for  it  is  essential  to  com- 
plete the  suturing  as  quickly  as  possible  after  the  intima  has  been  exposed. 


^Horsley,  J.  S.:     Olive  Oil  in  Blood  Vessel  Suturing,  Ann.   Surg.,  April,   1918,  pp.   469-471. 


80 


OPKRA'I'IVI':    SrRGF.RY 


One  of  the  sutures,  which  has  Ix'cii  jn-epared  as  directed,  is  inserted  from 
without  inward  at  one  end  of  the  artery  and  from  within  outward  at  the 
other  end.  An  artery  is  quite  tough  and  a  small  bite  will  he  sufficient.  If 
too  big  a  bite  is  taken,  the  intima  cannot  be  properl}^  everted.  The  first 
loop  of  a  knot  is  tied,  bringing  the  ends  of  the  vessel  together.  The  second 
loop  of  the  knot  is  tied  while  holding  the  ends  of  the  suture  taut,  running 
the  knot  down  in  this  manner  to  prevent  the  first  loop  slipping.  Olive  oil 
is  dropped  on  the  vessel  ends  every  20  or  30  seconds  to  prevent  drying. 
After  tying  this  suture,  the  arterial  suture  staff  is  placed  under  the  artery 


Fig.  36. — The  threaded  end  of  this  second  guy  suture  is  left  long  for  future  suturing.  The  un- 
threaded end  is  cut  short.  The  vessel  can  now  be  lifted  on  the  staff  and  the  apex  of  the  retracted  mar- 
gins indicates  the  point  of  insertion  for  the  third  guy  suture.  The  staff  makes  the  insertion  of  the  sec- 
ond,  and,  particularly,   the  third  guy  suture   much  easier. 

with  the  short  shaft  pointing  toward  the  operator.  Each  of  the  buttons 
of  the  staff  is  daubed  with  vaseline  to  make  the  sutures  hold  better  when 
wrapped  around  the  buttons.  The  vaseline  should  not  touch  the  intima  of  the 
vessel.  The  guy  suture  is  fastened  by  wrapping  it  two  or  three  times  around 
the  lowest  button  on  the  long  shaft,  and  is  cut  short  (Fig.  34).  The  length 
of  the  suture  from  the  button  to  the  vessel  should  be  about  half  an  inch. 
The  second  suture  is  placed  about  one  third  of  the  distance  around  the  circum- 
ference of  the  vessel  and  should  be  on  the  side  away  from  the  operator. 
The  suture  staff  is  laid  flat  so  that  the  short  shaft  is  not  in  the  way  and  the 
vessel  ends  rest  upon  the  long  shaft,  thus  making  it  easier  to  place  the  second 


SUTURING    r.T-OOD   VESSELS 


81 


suture  (Fig.  35).  The  second  suture  is  inserted  and  tied  in  the  same  manner 
as  the  first  and  is  wrapped  around  one  of  the  upper  buttons  on  the  long  shaft. 
The  threaded  end  is  left  long  for  future  suturing,  l)ut  the  other  end  is  cut 
close  to  the  l)ult()n.  As  two  guy  sutures  are  now  fixed  to  the  long  shaft,  the 
third  one  is  easily  inserted  by  raising  the  long  shaft,  when  the  point  of  in- 
sertion of  the  third  suture  is  indicated  by  the  retraction  of  the  margins  of  the 
artery.     The  needle  is  inserted  at  the  apex  of  the  retracted  margin  (Fig.  36). 


Fig.  37.— After  insertion  of  the  third  guy  suture,  it  is  tied  m  the  usual  manner  and  'he  staff  is 
grasped  by  the  handle  as  indicated  in  this  drawing,  and,  while  the  short  shaft  is  slightly  compiessea  lo- 
ward  the  long  shaft,  the  third  guy  suture  is  wrapped  around  one  of  the  buttons  on  the  end  ot  ttie  snort 
shaft. 

After  this  suture  is  tied,  the  short  shaft  is  slightly  compressed  toward  the 
long  shaft  and  this  guy  suture  is  wrapped  around  one  of  the  buttons  on  the 
end  of  the  short  shaft  (Fig.  37).  The  threaded  end  is  left  long  and  the 
unthreaded  end  is  cut  close,  as  was  done  in  the  second  suture.  It  is  im- 
portant to  have  no  unnecessary  ends  hanging  loose.  The  short  shaft  is  re- 
leased and  the  spring  makes  tension  on  the  margins  of  the  artery,  converting 
its  circumference  into  a  triangle,  and  everting  the  intima  (Fig.  38).     Olive 


82 


OPERATIVE   SURGERY 


oil  should  be  dropped  on  the  vessel  ends  from  time  to  lime  diiriii.<>'  these  manip- 
ulations and  during  the  suturing. 

The  three  guy  sutures  are  inserted  in  tlie  same  way  when  an  artery  is 
joined  to  a  vein  of  much  larger  caliber  as  when  a  divided  artery  is  united. 
Sometimes  it  is  a  little  more  dil^cult  to  place  the  guy  sutures  properly  when 
a  small  artery  is  sutured  to  a  large  vein  as  in  direct  transfusion,  but  after 
the  guy  sutures  are  once  inserted,  the  rest  of  the  procedure  1*8  identical, 
whether  vessels  of  equal  or  unequal  caliber  are  to  be  united. 

"We  now  have  two  needles  from  the  two   guy  sutures  last  inserted.     A 


Fig.  38. — When  the  tension  of  the  spring  of  the  shaft  is  released  by  removing  the  hand,  the  spring 
makes  traction  on  the  three  guy  sutures,  so  converting  the  circumference  of  the  vessel  into  a  triangle,  and 
everting  the   intima. 


needle  is  taken  in  each  hand  and  thrust  through  both  margins  of  the  artery 
in  the  region  where  the  second  suture  was  tied.  The  threaded  needle  from  the 
third  guy  suture  at  the  end  of  the  short  shaft,  will,  of  course,  carry  a  little 
loop  of  thread  which  is  of  no  consequence.  The  instrument  is  lifted  so  as 
to  elevate  the  upper  third  of  the  arterial  wound  and  increase  the  eversion.  The 
suture  is  then  applied  in  the  manner  of  tlie  double  mattress,  or  cobbler's  stitch, 
going  from  the  second  guy  suture  to  the  third  (Fig.  39).  At  the  angles  par- 
ticular care  should  be  taken  to  go  beneath  the  insertion  of  the  guy  sutures ; 
otherwise,  the  tension  of  the  guy  sutures  ma.y  produce  a  Avound  in  the 
endothelium  which  would  be  exposed  to  the  lumen  of  the  vessel.     After  the 


SUTURING    BI.OOD   VESSELS 


83 


first  tliii'd  has  been  sului'od,  tlio  liaiuUc  of  llic  suture  s1alT  is  dcjii-essed  away 
from  the  operator  and  the  staff  shoved  toward  the  operator  so  as  to  increase 
the  eversion  of  this  third  of  the  margin  of  the  vessel  (Fig.  40).  The  suturing 
is  continued  as  a  eo1)l)lcr's  stitch.  AVhen  tlie  second  third  is  finished,  the 
instrument  is  brought  to  its  original  position  aiul  each  needle  is  carried  under 
the  vessel  so  as  to  be  ready  for  suturing  the  hist  third.  The  handle  is  then 
depressed  toward  the  operator  and  held  in  such  a  manner  as  to  lift  up  the 
last  third  and  so  increase  its  eversion  (Fig.  41).  The  suturing  is  continued 
through  the  last  third  and  when  this  is  finished   the   instrument  is  brought 


Fig.  39. — The  handle  of  the  staff  is  upright  and  the  whole  instrument  is  lifted  up  so  as  to  increase 
the  eversion  of  the  intima.  The  continuous  double  mattress  or  cobbler's  stitch  is  begun  by  using  the 
threaded  ends  of  the  last  two  guy  sutures.  The  needles  are  thrust  through  the  margins  of  the  artery  near 
the  second  guy  suture  and  are  inserted  at  right  angles  to  each  other,  so  they  can  be  more  readily  handled. 
The   suturing  in  this   third  is  done  toward  the  operator — that   is,   from  the   second  to   the   third   guy   suture. 

to  its  original  position  and  the  suturing  carried  about  two  stitches  beyond 
the  point  of  beginning,  where  the  threads  are  tied  to  each  other.  Each  stitch 
must  be  drawn  snugly  when  it  is  placed,  else  the  intima  Avill  not  be  securely 
approximated  and  there  will  be  leakage.  In  the  carotid  of  a  dog  of  medium 
size  about  five  stitches  are  put  in  each  third  of  the  artery. 

Sometimes  retraction  of  the  ends  of  the  artery  is  marked  and  the  sutures 
cannot  be  properly  placed,  as  they  wall  tend  to  cut  out  or  break  under  the 
tension.  If  the  adventitia  of  the  vessel  is  grasped  with  curved  mosquito  for- 
ceps about  one  and  one-half  inches  from  the  severed  ends,  the  two  ends  of  the 


84 


OPERATIVE   SURGERY 


vessel  can  be  shoved  together  hy  an  assistant,  withont  tension  on  the  sutures 
and  without  his  hands  being  in  the  way  of  the  operator.  This  is  better  than 
trying  to  approximate  the  ends  by  tlie  serrefine  clamps  which  may  either 
come  off  or  loosen  and  flood  tlie  vessel  Math  blood. 

After  the  suturing  has  been  completed,  the  short  sliaft  is  slightly  compressed 
toward  the  main  shaft  so  as  to  relax  the  tension  on  the  guy  sutures  and  the  distal 
clamp  on  the  vessel  is  slowly  released  (Fig.  42).  If  there  is  marked  spurting  at 
any  point,  an  extra  suture  is  placed  there.  With  a  little  experience  spurting 
rarely  occurs,  though  there  is  usually  oozing  of  a  few  drops  of  blood.    The  guy  su- 


Fig.  40. — The  handle  of  the  staff  is  depressed  until  it  is  horizontal  and  points  away  from  tlie  oper- 
ator. Then  the  whole  instrument  is  shoved  toward  the  operator  so  as  to  increase  the  aversion  of  the 
second  third.     The   suturing  is  continued   as  a   cobbler's  stitch. 


tures  are  then  cut  and  the  instrument  is  removed.  The  sutured  vessel  is  very 
gently  compressed  with  drj^  gauze  and  the  distal  clamp  is  entirely  removed.  After 
about  three  minutes  the  proximal  clamp  is  slowly  removed.  In  this  time  the 
needle  holes  should  be  plugged  with  fibrin  and  there  should  be  no  leakage. 
The  vessel  must  not  be  returned  to  its  bed  until  leakage  has  ceased.  The 
whole  procedure  of  suturing  the  vessel  from  the  insertion  of  the  guy  sutures 
to  the  last  stitch,  can  easily  be  done  in  from  ten  to  fifteen  minutes  and  often 
in  less  time.  Any  competent  surgeon  who  tries  this  technic  experimentally 
a  few  times  can  master  it  (Figs.  43  and  44). 


SUTURING    BLOOD   VESSELS 


85 


The  traiisplaiitatioii  of  a  segment  of  a  vein,  or  of  an  artery,  involves 
the  same  teehnie  as  suturing  a  divided  vessel.  It  is  best,  however,  to  have 
two  arterial  suture  staffs  instead  of  one.  Three  guy  sutures  should  be 
placed  at  one  end,  but  only  the  first  two  fastened  to  the  staff.  Then  the  other 
end  of  the  transplant  can  be  sutured  with  another  staff  in  the  usual  way. 
After  this  is  completed,  the  first  staff  is  taken  up,  and  the  third  guy  suture 
fastened  to  the  end  of  the  short  shaft,  and  the  suturing  completed.  In  this 
way  there  is  no  inconvenience  from  the  presence  of  two  suture  staffs  in  the 
wound  at  the  same  time,  for  if  all  three  guy  sutures  w^ere  placed  in  posi- 
tion on  the  first  suture  staff,  the  short  end  of  the  staff  Avould  project  so  as 


Fig.  41.— The  handle  of  the  staff  is  brought  over  to  a  horizontal  position,  pointing  toward  the  opei- 
ator.  The  instrument  is  lifted  up  so  as  to  increase  the  eversion  in  the  last  third.  The  suturing  is  con- 
tinued from  the  first  to  the  second  guy   suture. 

to  interfere  with  the  suturing  at  the  second  suture  staff.  A  transplant  can 
be  taken  from  either  a  vein  or  an  artery.  For  practical  purposes  the. vein  is 
better.  In  experimental  work  the  external  jugular  of  the  dog  is  the  most 
suitable  vein  to  transplant.  It  is  readily  accessible,  is  large,  and  has  but  few 
branches.  Transplantation  after  resection  of  the  carotid  is  more  likely  to 
be  successful  in  experimental  work  than  transplanting  in  the  femoral  because 
the  neck  is  much  less  likely  to  be  infected  than  the  leg  (Figs.  45  and  46). 
This  has  been  jjointed  out  by  Stephen  Watts. 

Some   attention  must  be   given   to   securing   a   section  of  the  vein  that 


86 


OPERATIVE    SURGERY 


is  to  be  transplanted.  The  saphenous  is  the  best  A'ein  to  use  as  a  transplant 
in  man.  The  vein  must  be  exposed  and  handled  gently.  A  much  longer 
portion  should  be  taken  than  is  supposed  to  be  necessary,  for  it  contracts 
greatly  after  being  removed  and  it  is  a  simple  matter  to  cut  off  any  excess 
if  it  is  too  long.  The  vein  is  dissected  free  while  it  is  distended  with  blood 
and  the  adventitia  of  that  portion  of  the  vein  to  be  cut  is  very  carefully 
removed  while  the  vein  is  distended;  otherwise  it  retracts  within  the  adven- 
titia  and   as   the   vein    is    exceedingly    thin,    cleaning    away    the    adventitia    ls 


Pig,    42. The    handle    of    the    instrument   is   brought   to    a   vertical    position    and    the    sutures,    having 

been  carried  about  two  stitches  beyond  the  point  of  commencement,  are  tied  to  each  other.  The  distal 
clamp  is  slowly  removed  and  the  staff  somewhat  compressed  in  order  to  relax  the  guy  sutures  and  dem- 
onstrate if  there  is  any  spurting  point  along  the  suture  line.  After  a  minute  the  other  serrefine  is  re- 
moved if  no  spurting  occurs,  and  the  guy  sutures  are  cut.  If  there  is  spurting,  the  clamps  can  be  re- 
applied and  an  extra  stitch  taken  at  the   spurting  point. 

difficult  after  the  collapsed  segment  has  been  removed.  When  the  adventitia 
has  been  sufficiently  removed,  the  serrefine  that  caused  the  vein  to  become 
distended  is  released  and  a  ligature  is  placed  on  the  distal  portion  of  the  vein. 
The   blood   is   then   gently   stripped   out   of   the   vein   and   another   ligature 


SUTURING    BLOOD   VESSELS 


87 


placed  at  the  proxiuial  cud.  The  vein  is  severed  witli  sliarp  scissors,  with  one 
stroke  if  possible.  After  the  blood  has  been  stripped  from  the  vein  it  is  en- 
tirely collapsed  and  like  a  ribbon.  ^N]\en  the  end  is  cut  it  is  sponged  with 
dry  gauze  and  thoroughly  anointed  with  olive  oil,  as  mentioned  in  the  tech- 
nic  for  vessel  suturing  (page  79),  only  more  olive  oil  should  be  used  here. 
The  other  end  is  then  divided  and  treated  in  a  similar  manner.  The  vein  should 
be  used  as  quickly  as  possible.  The  vein  should  not  be  removed  until  the  other 
dissection  has  been  completed,  so  that  suturing  of  the  vein  into  the  defect  can  be 
proceeded  with  at  once.  The  segment  of  vein  should  not  be  washed  out  or  kept 
in  salt  solution.  If  for  any  reason  it  is  necessary  to  keep  the  segment  a  while,  it 
may  be  placed  on  a  towel  or  piece  of  gauze  that  has  been  wrung  out  in  salt  solu- 
tion, and  another  piece  of  gauze  similarly  wrung  out,  is  placed  over  it.    It  is  not 


Fig.  43.— A  femoral  artery  of  a  dog  removed  a  few  minutes  after  suturing,  after  the  blood  had  been 
turned  on  and  no  leakage  appeared.  Note  the  eversion  of  the  mtima  which  makes  a  flange  without  dim- 
inution of  the  caliber.  . 

Fig.  44.— The  lumen  of  the  carotid  artery  of  a  dog  after  suturing  according  to  the  author's  technic. 
The  blood  had  been  turned  on  and  allowed  to  run  a  few  minutes.  Note  the  small  amount  of  tiiread  in 
the  lumen. 

necessary  for  the  salt  solution  to  be  warm.  It  has  been  proved  that  cold  tends  to 
retard  thrombus  formation,  and  segments  of  vessels  can  be  kept  in  cold  storage 
for  weeks  and  then  sutured  successfully. 

I  have  used  experimentally  rubber  tubing  of  various  kinds  to  replace 
an  arterial  segment.  This,  in  most  instances,  becomes  readily  covered  w^ith 
tissue  that  resembles  the  adventitia  of  a  blood  vessel.  It  is  well  known  that 
rubber  when  properly  prepared  is  very  slightly  irritating  to  the  tissues. 
Dentists  make  frequent  use  of  it.  If,  then,  adventitia  can  be  thrown  around 
the  rubber  tube  as  an  encapsulation,  it  would  probably  support  the  blood 


88 


OPERATIVE    SURGERY 


current  after  the  rubber  had  degenerated.  The  high  reproductive  power 
of  vascular  endothelium  is  frequently  observed  in  the  rapid  lining  of  aneur- 
isms that  have  suddenly  enlarged,  and  it  seems  possible  that  this  endothelium 
might  cover  the  inner  surface  of  the  rubber  tubing.  Theoretically,  in  this 
way  a  strong  adventitia  and  an  intima  may  be  secured.  Experimentally, 
however,  I  have  not  been  able  to  obtain  such  a  result.  Though  the  tube  is 
often  encapsulated  with  a  membrane  that  resembles  adventitia,  its  internal 


Fig.  45. 


Fig.  46. 


Pig.  45. — The  end  of  the  carotid  artery  was  sutured  to  the  distal  end  of  the  divided  external  jugular 
vein  in  a  dog,  and  this  specimen  was  removed  after  thirty-nine  days.  The  sutures  are  distinctly  buried, 
though  the  endothelium  over  them  is  transparent  in  places.  The  line  of  suturing  is  smooth.  A  short  dis- 
tance  from  the  line  of  suturing  are  the  crumpled  up  valves  which  were  broken  down  by   the  blood   stream. 

Fig.  46. — A  segment  of  the  external  jugular  vein  was  sutured  in  the  place  of  a  resected  portion  of 
the  carotid  of  a.  large  dog.  The  valves  are  about  the  middle  of  the  specimen,  and  at  this  point  the  trans- 
planted vein  was  dilated.  Otherwise,  the  intima  is  smooth  and  the  sutures  mostly  buried  from  view.  The 
specimen  was  removed  sixty-three  days  after  operation. 


Burfaee  has  so  far  been  invariably  blocked,  sooner  or  later,  by  thrombus. 
Tubes  have  varied  from  thick,  black  rubber  to  very  thin  rubber,  and  have 
been  coated  with  vaseline  or  paraffin.  "While  it  Avould  be  impossible  to  suture 
tubes,  especially  thick  tubes,  by  the  overhand  stitch,  and  at  the  same  time 


SUTURING   BLOOD   VESSELS  89 

make  an  aeeurate  a])proxiinati()ii  and  avuid  sharp  edges  of  the  tiil)e  pointing 
inward,  by  using  a  mattress  suture,  and  preferably  the  double  mattress  with 
the  staff,  that  has  been  described,  sharp  edges  are  everted.  While  so  far  I  have 
not  met  with  success  in  having  the  rubber  tube  remain  permanently  patent,  the 
thrombus  formation  in  some  instances  at  least  must  have  been  slow.  Clinically 
it   is  almost  as  satisfactory   to   have   a   slowly  forming   thrombus   in   a   tube 


Fig.  47. — Photograph  of  a  specimen  in  which  a  rubber  tube  was  sutured  into  the  defect  caused  by- 
excision  of  a  portion  of  the  abdominal  aorta  of  a  dog.  This  specimen  was  removed  after  six  months,  and 
the  tube,   which  had  been  sutured  according  to   the   method   described,   was   completely    encapsulated,   though 


90  OPERATIVE    SURGERY 

of  this  character,  which  would  permit  collateral  circulation  to  form,  as  it  is 
to  have  the  tube  remain  permanently  open. 

The  possibility  of  using  a  rubl)cr  tube  in  this  manner  clinically  has 
been  suggested  by  an  experiment  in  which  a  portion  of  the  abdominal  aorta  of 
a  dog  was  resected  and  a  piece  of  rubber  tube  transplanted  to  fill  the  defect. 
The  portion  resected  was  below  the  renal  arteries.  The  tube  Avas  a  soft, 
black  rubber  tube  coated  with  paraffin.  It  was  much  thicker  than  was 
really  necessary,  and  the  suturing  was  more  difficult  than  if  a  thinner  tube 
had  been  used.  The  dog  was  a  medium  sized  female  mongrel.  There  was 
very  little  leakage,  which  was  easily  controlled  by  pressure.  The  peritoneal 
tissues  were  sutured  over  the  tube.  The  dog  made  a  satisfactory  recovery, 
there  being  no  paralysis  of  the  hind  legs.  As  function  had  apparently  not  been 
interfered  with,  it  was  hoped  that  the  tube  had  remained  patent.  Six  months 
after  this  operation  the  dog  appeared  in  perfect  health.  The  dog  was  then 
photographed,  killed  with  chloroform,  and  the  specimen  removed.  The  lumen 
of  the  tube,  however,  was  occluded  with  a  thrombus.  There  was  no  dilatation 
nor  any  evidence  of  formation  of  an  aneurism.  The  outline  of  the  tube  is 
plainly  seen  in  the  photograph.  The  external  caliber  of  the  tube  was  con- 
siderably larger  than  the  external  caliber  of  the  artery  (Fig.  47). 

Ligation  of  the  aorta  in  man  has  been  universally  fatal.  This  experiment 
suggests  a  possible  substitute  for  ligation. 

LATERAL  AND  INCOMPLETE  TRANSVERSE  WOUNDS  OF  BLOOD 

VESSELS 

The  preliminary  steps  in  suturing  lateral  or  transverse  wounds  of  blood 
vessels  are  the  same  as  those  outlined  under  the  description  of  end-to-end 
suturing.  The  wound  should  be  a  clean  cut.  If  ragged  or  bruised,  the  mar- 
gins are  trimmed  with  sharp  scissors.  If  a  transverse  wound  involves  more 
than  half  the  circumference  of  a  vessel,  the  vessel  should  be  completely  di- 
vided and  then  united  by  the  end-to-end  method.  If  the  whole  circumference 
is  contused  or  lacerated,  the  damaged  section  must  be  excised,  and  if  the  ends 
of  the  vessel  cannot  be  sutured  together  without  too  much  tension,  a  trans- 
plant of  vein  may  be  used. 

The  method  to  be  adopted  in  suturing  these  wounds  depends  partly 
upon  the  nature  of  the  wound,  but  largely  upon  the  accessibility  of  the  blood 
vessel.  AVhen  possible,  the  vessel  should  be  freely  exposed  by  a  long  ex- 
cision. The  adventitia  along  the  edges  of  the  wound  is  trimmed  away  with 
sharp  scissors,  blood  clots  are  removed,  and  the  edges  of  the  wound  and  the  in- 
tima  are  waslied  with  Locke's  solution.  If  the  wound  is  parallel  with  the  vessel, 
it  may  be  grasped  Avith  the  forceps  used  for  lateral  anastomosis  of  blood 
vessels  or  arteriovenous  aneurism  and  sutured  with  a  cobbler's  stitch,  using 
fine,  straight  needles  (Xo.  14  or  16)  and  fine  black  silk  sterilized  in  vaseline. 
If  the  wound  is  transverse,  the  suture  staff  may  be  placed  under  the  vessel, 
a  guv  suture  of  the  usual  material  is  inserted  at  one  end  of  the  wound  and 


SUTURING    BLOOD   VESSELS  91 

wrapped  around  an  upiier  button  on  the  long  sliaft,  and  anotlicr  guy  sutnre 
is  placed  at  the  opposite  end  of  the  wound  and  fastened  to  a  button  on  the 
short  shaft  Avhile  it  is  being  compressed  toward  the  long  shaft.  When  the 
short  shaft  is  released,  it  Avill  make  tension  on  the  wound  and  evert  the 
intima.  A  cobbler's  stitch  can  then  be  placed  with  the  thi'eaded  ends  of 
the  gny  sutures,  as  in  suturing  the  first  third  of  an  end-to-end  union.  Care 
should  be  taken  to  secure  the  beginning  of  the  suture  line  by  going  Avell 
beyond  the  wound  and  taking  a  back  stitch.  Occasionally  a  transverse  or  a 
lateral  wound  may  be  so  inaccessible  that  neither  of  these  methods  can  be 
used.  Here  a  long  guy  suture  may  be  placed  at  each  end  of  the  Avound  and 
held  by  an  assistant  while  the  wound  is  closed  with  a  continuous  overhand 
stitch  of  black  silk  in  a  fine  curved,  round  needle.  There  wall  be  more  leakage 
from  the  needle-holes  after  this  method  and  thrombosis  is  more  frequent,  but  in 
deep  wounds  it  may  be  the  only  technic  applicable. 


CHAPTER  VII 
REVERSAL  OF  THE  CIRCULATION 

The  therapeutic  value  of  attempts  to  reverse  the  circulation  in  the  ex- 
tremities has  been  freely  discussed  since  this  work  was  first  brought  to  the 
attention  of  surgeons  by  the  experiments  of  Carrel.  Carrel  and  Guthrie^  reached 
the  following  conclusions  as  the  result  of  two  experiments;  "(a)  The  valves 
prevent,  at  first,  the  reversion  of  the  circulation  in  the  veins,  (b)  After  a 
short  time,  the  valves  gradually  give  way  and  the  red  blood  floAvs  through  the 
veins  as  far  as  the  capillaries,  (c)  Finally  it  passes  through  the  capillaries 
and  the  arteries  are  filled  with  dark  blood.  Probably  dark  blood  also  returns 
from  the  capillaries  towards  the  heart  through  some  veins,  (d)  Practically 
complete  reversal  of  the  circulation  is  established  about  three  hours  after 
the  operation." 

The  clinical  indication  for  reversal  of  the  circulation  has  been  thought 
to  be  threatened  or  slow  gangrene  of  the  foot  or  occasionally  of  the  hand. 
The  lower  extremity  is  far  more  frequently  threatened  with  gangrene  than 
the  upper  extremity.  This  may  be  due  to  the  fact  that  it  is  longer  and  the 
distance  from  the  base  of  nutrition  is  consequently  greater  and  that  the  cir- 
culation has  to  overcome  the  weight  of  the  column  of  blood  that  must  be 
lifted  from  the  foot,  which  is  far  greater  than  would  be  the  pressure  of  the 
returning  blood  circulation  from  the  upper  extremity. 

The  diseases  in  which  slow  or  threatened  gangrene  usually  occurs  are;  (1) 
arteriosclerosis,  (2)  intermittent  claudication,  (3)  Raynaud's  disease,  and  (4) 
thromboangiitis  obliterans.  In  all  of  these  diseases  the  artery  is  usually 
more  profoundly  affected  than  the  vein.  It  has  been  suggested  as  a  result 
of  the  ^experimental  work  of  Carrel  and  Guthrie  that  the  vein  could  take 
on  the  function  of  the  artery,  and  in  slow  or  threatened  gangrene  of  the 
foot  the  femoral  artery  could  be  divided  in  its  upper  portion,  the  femoral 
vein  also  divided  at  a  same  level  and  the  cardiac  end  of  the  artery  sutured 
to  the  distal  end  of  the  vein,  the  distal  end  of  the  artery  being  sutured  to 
the  cardiac  end  of  the  vein.  In  this  way  the  blood  in  the  femoral  artery  enters 
the  femoral  vein  and  is  supposed  to  overcome  the  obstacles  of  the  valves  in 
the  vein,  gradually  to  reach  the  terminal  veins  and  capillaries,  and  then  is 
returned  through  another  system  of  veins  that  would  anastomose  with  the 
branches  of  the  iliac  veins. 

In  order  to  determine  the  exact  course  of  the  reversed  circulation,  a  series 
of  experiments  on  dogs  was  undertaken,  the  results  of  which  have  been 
reported  elsewhere.-     The  late  Dr.  R.  H.  AVhitehead,  who  was  Professor  of 


^Ann.   Surg.,   February,  1906,   p.   212. 

2Jour.  Am.  Med.  Assn.,  March   13,   1915,  Ixiv,  873-877;  Ann.   Surg.,  March,   1916. 

92 


REVERRAT.    OF    THE    CIRCULATION 


93 


Anatomy  in  the  University  of  Virginia,  dissected  the  specimens  and  reported 

that  the  dissections  corresponded  in  all  essentials  with  the  roentgenograms. 

DeWitt  Stetten,  of  New  York,  worked  on  the  same  problem  nsing  liml)S 

that  had  l)een  amputated  for  affections  in   which  reversal  of  the  circulation 


Fig.  48. — A  roentgenogram  of  reversal  of  the 
circulation  in  a  dog's  hind  extremity  which  was 
injected  with  cinnabar  mass  a  half -hour  after 
operation.  The  mass  goes  only  a  little  below  the 
knee  and  returns  in  the  back  part  of  the  thigh 
toward  the  branches  of  the  internal  iliac  vein. 


Fig.  49. — A  roentgenogram  of  cinnabar  mass 
which  was  injected  into  the  reversed  circulation  of 
a  dog's  hind  extremity  twenty-two  days  after  the 
operation.  Note  the  very  large  collateral  veins 
that  conduct  the  mass  easily  to  the  iliac  veins  and 
the  vena  cava. 


Fig.  SO. — A  roentgenogram  of  cinnabar  mass 
injected  into  reversed  circulation  of  the  hind  ex- 
tremity of  a  dog  sixty-nine  days  after  the  oper- 
ation. 


Fig.  51. — A  roentgenogram  of  the  same  dog 
shown  in  Fig.  SO,  but  with  the  systemic  arterial 
system  injected  with  a  bismuth  mass  through  the 
carotid.  Note  the  excellent  circulation  in  the  foot. 
The  black  shadow  in  the  body  is  due  to  rupture 
of  some  abdominal  vessel  toward  the  end  of  this 
injection  which  permitted  the  peritoneal  cavity 
to  be  filled  with  the  bismuth  mass. 


94  OPERATIVE    SURGERY 

had  been  formerly  recommended."'  In  liis  excellent  article,  which  goes  very 
fully  into  the  literature  of  the  subject,  he  arrived  at  the  same  conclusion 
Avhich  Ave  had  reached  by  our  exiDcrimental  work  on  dogs. 

Briefly  summarizing  the  results  of  these  experiments,  thirteen  dogs  were 
operated  upon  by  severing  the  femoral  artery  and  femoral  vein  just  below 
Poupart's  ligament  and  suturing  the  cardiac  end  of  the  artery  to  the  distal 
end  of  the  vein  by  the  teehnic  described  in  the  previous  chapter.  This  tech- 
nic  stands  infection  better  than  the  teehnic  of  Carrel,  as  it  apposes  a  broader 
surface  of  endothelium  and  makes  a  firmer  and  more  resistant  union.  These 
dogs  were  killed  within  periods  of  time,  varying  from  half  an  hour  to  sixty- 
nine  days  after  the  operation.  The  femoral  artery  just  above  the  point  of 
the  anastomosis  was  injected  with  a  cinnabar  and  gelatine  mass  under  con- 
siderable pressure.  Eoentgenograms  w^ere  then  taken  and  afterwards  the 
general  arterial  circulation  was  injected  with  a  bismuth  mass  either  from  the 
aorta  or  the  carotid.  Both  bismuth  and  cinnabar  are  impervious  to  x-ray 
and  the  ditference  in  color  prevents  confusion  in  dissection.  In  no  instance 
did  the  reversed  circulation,  as  shown  by  the  injection  of  the  cinnabar,  go  as 
far  as  the  foot  and  in  every  case  except  one  it  extended  but  a  short  distance 
below  the  knee.  The  tendency  of  the  arterial  blood  in  the  reversed  femoral 
vein  is  to  return  to  the  vena  cava  by  the  nearest  anastomotic  route  (Figs.  48, 
49,  50  and  51).  The  longer  the  period  of  time  after  the  operation,  and  the  more 
abundant  the  collateral  circulation,  the  easier  is  the  return  to  the  vena  cava. 

Evidentl}^  what  happens  is  that  the  large  valves  in  the  large  veins  are 
first  quickly  broken  down.  The  arterial  blood  in  the  reversed  vein  then 
rushes  into  smaller  veins.  The  smaller  valves  in  the  smaller  veins  require 
relatively  more  force  to  overcome  them  than  the  larger  valves  in  the  large 
veins,  because  of  the  relation  of  cubic  contents  to  square  surface.  The  ex- 
periments show  that  the  reversed  circulation  went  but  little  further  doAvn 
the  leg  in  a  dog  sixty-nine  days  after  operation  than  it  did  in  the  dog  that 
Avas  injected  a  half  hour  after  the  circulation  Avas  rcA'ersed.  This  seems  to 
show  that  the  A'ah^es  AAdiich  are  not  broken  doAvn  in  the  first  feAV  minutes  Avill 
probably  hold  permanently.  Collateral  circulation  quickly  increases,  and 
large  veins  are  formed  Avhich  readily  carry  the  reversed  blood  to  the  branches 
of  the  iliac  A'ein.  In  this  Avay  the  pressure  upon  the  obstructing  A^alves  is  re- 
duced and  probably  some  thickening  of  these  vah^es  occurs.  Instead,  then,  of 
the  constant  pounding  of  the  heart  tending  to  break  cloAvn  these  A'ah^es,  it 
seems  to  do  just  the  opposite.  Valves  that  are  not  overcome  AA^thin  the 
first  fcAV  minutes  haA^e  less  and  less  pressure  upon  them  until  the  collateral 
circulation  dcA^elops  to  its  maximum. 

HoAv,  then,  can  avc  account  for  the  apparent  improA'ement  in  many  of 
the  reported  cases  of  reversal  of  the  circulation  in  patients?  Certainly  not 
all  of  these  reports  can  be  argued  aAA^ay,  and  they  must  rest  on  some  basis 
of  fact.  In  the  successful  cases  reported,  it  has  been  usual  to  find  that  the 
day  after  the  operation  the  foot  appears  Avarmer  and  the  color  is  better  than 


^Surg.   Gynec.  &  Obst.,  April.   191S. 


REVERSAL    OF    THE    CIRCULATION  95 

before  operation.  It  has  been  asserted,  tlierefore,  tliat  tlie  improvement  must 
be  accounted  for  by  the  operation  and  by  the  fact  that  the  arterial  blood  is 
reaching  the  distal  part  of  the  foot  through  the  reversed  vein.  A  great  many 
reversals  of  the  circulation  have  been  done  b}'  surgeons  untrained  in  blood 
vessel  surgery  who  liave  used  the  end-to-end  method,  and  it  is  natural  to  ex- 
pect that  there  will  be  a  large  percentage  of  occlusions  by  thrombosis  fol- 
lowing sucli  work.  In  no  other  branch  of  surgery  is  laboratory  experience  so 
essential  as  in  preserving  a  patent  lumen  after  suturing  blood  vessels.  It  is 
easy  enough  to  unite  the  artery  and  vein  so  that  the  line  of  union  will  not 
•bleed  at  the  conclusion  of  the  operation,  but  the  technically  successful  opera- 
tion is  the  one  in  which  the  lumen  remains  permanently  patent.  These  tem- 
porary improvements  may  be  explained  in  the  following  manner : 

The  cause  of  the  impending  gangrene  for  which  these  operations  are 
done  is  a  diminished  lumen  of  the  artery,  while  the  veins  are  but  little  if 
at  all  affected.  An  artery  that  would  normally  carry  100  per  cent  of  its  ca- 
pacity is  under  these  altered  conditions  carrying  only,  saj"  25  per  cent,  but 
the  capacity  of  the  vein  has  been  but  slightly  altered.  Nutrition  for  the 
tissues  is  taken  from  the  arterial  blood  in  the  capillaries  and  depends  not  only 
on  the  quantity  and  quality  of  this  blood  and  the  ability  of  the  tissues  to 
absorb  it,  but  also  to  some  extent  on  the  length  of  time  during  which  the  arterial 
blood  bathes  the  tissues.  With  the  artery  working  normally  and  the  veins 
normally,  a  definite  period  of  time  during  which  the  arterial  blood  remains  in 
the  tissues  is  maintained ;  but  with  the  capacity  of  the  artery  cut  down  to 
about  one  fourth  of  normal  or  even  less,  and  the  capacity  of  the  vein  but 
slightly  interfered  Avith,  the  small  amount  of  arterial  blood  that  does  reach  the 
tissues  is  drained  away  by  the  unobstructed  veins  more  quickly  than  normal. 
The  arteriovenous  anastomosis  stops  the  venous  current  in  the  femoral  vein 
either  by  the  force  of  the  reversed  arterial  blood  stream  or,  more  probably, 
particularly  Avhen  done  by  those  inexperienced  in  vascular  surgery,  by  throm- 
bosis at  the  site  of  the  operation.  This,  of  course,  obstructs  the  vein  and 
more  nearly  restores  the  balance  between  the  venous  and  the  arterial  cir- 
culation. In  other  words,  the  operation  dams  back  the  arterial  blood  in 
the  capillaries  so  that  instead  of  being  drained  off  too  rapidly,  the  arterial 
blood  is  compelled  to  stay  the  normal  time,  and  possibly  even  somewhat  longer 
than  normal,  and  so  gives  up  to  the  tissues  more  of  its  nutrient  properties. 
In  this  manner  the  improvement  as  to  the  color  and  warmth  of  the  affected 
limb  can  be  accounted  for.  But  if  the  occlusion  has  been  caused  by  thrombus 
formation  at  the  arteriovenous  anastomosis,  the  thrombus  may  extend  until  too 
much  of  the  venous  system  is  plugged,  and  gangrene  will  follow. 

The  same  results  can  be  obtained  much  more  accurately  and  with  less  danger 
simply  by  ligation  of  the  femoral  vein  under  a  local  anesthetic.  This  pro- 
cedure has  been  recommended  and  carried  out  by  von  Oppel,  Coenen,  Lilien- 
thal  and  others. 

In  operation  for  threatened  or  slow  gangrene  of  the  foot,  the  femoral  vein 
should  be  ligated  below  the  point  at  which  the  saphenous  vein  enters  it.  in 


96  OPERATIVE    SURGERY 

order  not  to  obstruct  too  much  of  the  returning  venous  circulation.  As  the 
condition  of  the  patients  with  threatened  or  slow  gangrene  is  serious  the 
operation  should  be  done  under  local  anesthesia. 

An  incision  of  about  three  inches  in  length  is  made  over  the  upper  por- 
tion of  the  femoral  artery  beginning  just  below  Poupart's  ligament.  The 
dissection  is  carried  down  until  the  femoral  artery  is  fully  exposed  in  the 
lower  half  of  the  incision.  The  femoral  vein  is  identified  internal  and  slightly 
posterior  to  the  femoral  artery  and  should  be  cleanly  dissected  in  front  with 
a  sharp  knife.  Bj^  the  method  of  inserting  closed,  curved  scissors  and  then 
opening  the  blades  the  vein  can  be  readily  isolated.  Care  is  taken  to  ex- 
pose the  femoral  vein  clearly  and  to  have  the  incision  sufficiently  long  to 
prevent  any  confusion  of  the  anatomical  structures.  A  ligature  is  passed 
around  the  femoral  vein  with  an  aneurism  needle.  It  is  best  to  apply  two 
ligatures  of  moderately  stout  catgut.  The  skin  is  sutured  with  silk  or  silk- 
worm-gut. The  leg  is  slightly  elevated  and  kept  warm.  Within  twenty-four 
hours  there  is  often  marked  improvement  in  the  condition  of  the  limb.  This  im- 
provement is  usually  not  permanent.  The  beneficial  results,  however,  are  fully 
as  great  as  those  obtained  from  anastomosing  the  artery  and  vein,  and  the  danger 
of  the  operation  is  far  less. 


CHAPTER  VIII 
LIGATION  OF  BLOOD  VESSELS 

One  of  the  chief  indications  for  ligation  of  the  blood  vessels  in  preanti- 
septic  days  Avas  secondary  hemorrhage  following  suppuration.  This  indication 
is  infrequent  noAV,  so  the  elaborate  operations  that  were  formerly  devised 
for  ligation  of  almost  every  artery  in  the  body  are  largely  unnecessary. 

On  account  of  aneurisms  there  is  often  occasion  for  tying  in  continuity 
the  larger  arteries,  as  the  carotid  or  its  branches,  subclavian,  axillary,  bra- 
chial, iliac,  femoral.  Occasionally,  on  account  of  hemorrhage  from  the  palmar 
arches  it  is  necessary  to  tie  the  radial  and  the  ulnar  arteries. 

Ligation  of  arteries  in  continuity  requires  a  clear  knowledge  of  the  anat- 
omy of  the  site  of  operation.  The  general  technic  of  ligating  vessels  holds 
good  for  the  tying  of  any  artery.  The  incision  should  be  made  as  directly 
over  the  vessel  to  be  ligated  as  possible.  This  should  be  determined  in  ad- 
vance and  is  based  upon  the  anatomy  of  the  parts.  Any  probable  or  possible 
variation  in  anatomy  from  the  normal  must  be  borne  in  mind  and  the  anatom- 
ical changes  that  may  be  produced  by  the  pathology  present,  as  in  ligating  in 
the  presence  of  great  swelling,  must  be  given  due  consideration.  The  incision 
should  be  sufficiently  long  to  expose  the  vessel  freely  and,  as  a  rule,  should  be 
so  placed  that  the  proposed  site  of  the  ligation  of  the  artery  wdll  be  in  the 
center  of  the  incision.  The  skin  incision  is  made  by  holding  the  skin  firmly 
with  the  fingers  and  thumb  of  the  left  hand  and  cutting  through  the  skin  in 
the  proposed  line  of  the  artery  with  one  stroke  of  the  knife.  The  superficial 
fascia  and  deep  fascia  are  then  divided.  All  vessels  that  are  in  the  way  are 
retracted  or  else  doubly  clamped  and  ligated,  so  as  to  give  a  clean  access  to  the 
artery.  When  approaching  close  to  the  artery,  the  loose  connective  tissue 
and  areolar  tissue  are  caught  with  thumb  forceps  and  lifted  and  cut  with  a 
sharp  knife.  It  is  dangerous  to  dissect  around  a  big  vessel  wdth  a  dull  knife, 
because  the  stroke  of  a  dull  knife  cannot  be  gauged  with  accuracy.  The 
artery  is  usually  distinguished  by  pulsation  if  no  tourniquet  is  used,  or,  if  a 
tourniquet  is  used,  by  the  fact  that  the  artery  is  thicker  and  not  collapsible 
as  the  vein  is.  Below  the  axilla  and  below  the  knee  each  artery  has  two  com- 
panion veins,  the  venae  comites,  which  may  serve  as  an  identification,  whereas 
the  larger  arteries  in  the  head  and  neck  are  accompanied  by  single  veins. 
The  nerves  appear  as  white  solid  cords.  Occasionally,  a  nerve  may  trans- 
mit pulsation  because  it  rests  on  an  artery,  but  if  grasped  gently  between 
the  finger  and  thumb  it  can  be  easily  seen  that  this  is  not  an  expansile  pulsa- 
tion but  merely  transmitted. 

Only  the  main  larger  arteries  have  a  distinct  sheath.  Usually  when  there 
is  a  sheath,  the  accompanying  vein  and  nerve  are  enclosed  in  a  common  sheath 

97 


98 


OPERATIVE    Sl'RGERY 


with  the  artery.  The  smaller  arteries  have  no  distinct  sheath,  but  are  merely 
surronnded  by  areolar  tissue.  In  the  large  arteries  the  sheath  should  be 
opened  at  least  half  an  inch  from  any  branch.  The  sheath  is  opened  by  pick- 
ing it  up  Avith  thumb  forceps,  making  traction  upon  it  so  as  to  pull  it  away 
from  the  artery  and  dividing  it  by  a  stroke  of  a  sharp  knife  in  the  axis 
of  the  vessel.  It  must,  of  course,  be  accurately  ascertained  before  divid- 
ing the  .sheath  that  the  forceps  does  not  include  the  vessel  Avail  also.  This  is 
not  likely  to  occur  but  can  be  easily  demonstrated  by  moving  the  sheath  to  and 
fro.  It  is  best  not  to  make  an  incision  into  the  sheath  longer  than  is  neces- 
sar}"  to  ligate  the  vessel  clearly,  as  too  extensive  a  separation  of  the  sheath 
from  a  large  arterA*  maA^  interfere  Avith  the  nutrition  of  the  Avails  of  the  ar- 


Fi? 


-Binnie's  method  of  passing  a  stout  catgut  ligature. 


tery.    If  necessary,  it  is  better  to  open  the  sheath  by  making  tAvo  short  incis- 
ions at  different  points  than  to  make  one  long  incision. 

The  ligature  is  passed  preferably  Avith  a  curved  aneurism  needle.  It 
may,  howcA^er,  be  more  convenient  to  use  a  small  right  angled  pedicle  clamp. 
The  only  objection  to  the  clamp  is  that,  AA'hen  its  jaAvs  are  opened  to  receive  the 
ligature  and  then  clamped  on  the  ligature,  it  is  possible  that  some  tags  of  tissue 
in  the  neighborhood  may  also  be  caught  in  the  forceps  and  prevent  the  free 
moA'ing  of  the  forceps.  This  can  usually  be  prevented  by  opening  and  clos- 
ing the  forceps  scA^eral  times  before  placing  the  ligature  in  its  grasp.  In  a 
deep  Avound,  hoAvcA^er,  the  aneurism  needle  is  preferable  to  the  right  an- 
gled forceps.  The  aneurism  needle  should  ])e  passed  around  the  artery  be- 
ginning on  the  side  of  the  vein.    In  the  larger  arteries,  moderately  stout  cat- 


LIGATION    OP    BI.OOD   VESSELS 


99 


gut  is  used.  If  tliis  is  threaded  into  tlic  aneurism  needle  before  the  ueedle  is 
passed,  it  maj^  interfere  with  passage  of  tlu^  needle.  It  is  a  good  idea  to  follow 
the  suggestion  of  Binnie  and  arm  the  needle  with  a  fine  thread  of  silk  or  linen 
which  does  not  hamper  the  manipulation  of  the  aneurism  needle.  When  the 
eye  of  the  aneurism  needle  has  appeared  on  the  opposite  side  of  the  vessel  from 
that  under  which  it  was  inserted,  the  loop  of  small  silk  or  linen  is  drawn  up 
and  the  stouter  catgut  is  passed  through  this  loop  and  so  drawn  around 
the  vessel  (Fig.  52). 

Ligatures  of  catgut  are  usually  best  and  if  tied  properly  the  knot  will 
hold.  The  so-called  surgeon's  knot  should  never  be  used  because  it  is  im- 
possible to   tell  how  much  pressure  is  being  taken  up   b}"   the   friction   of 


Fig.   53. — Ligation   of  the  femoral  artery,   showing   method   of  applying   two   ligatures.      The   ligature   nearest 
the  heart  takes   the   chief   strain   of   the   arterial   pressure. 

the  double  tie  and  how  much  by  the  vessel.  The  first  tie  can  be  held  by  grasping 
it  with  small  forceps,  such  as  mosquito  forceps,  while  the  second  tie  is  being 
run  down,  and  a  third  tie  should  always  be  placed  in  order  to  make  the  knot 
more  certain.  It  is  not  necessary  to  rupture  the  intima  but  sufficient  pres- 
sure should  be  made  by  the  first  tie  in  order  firmly  to  occlude  the  vessel.  If 
too  large  a  strand  is  used  there  is  much  more  likelihood  of  the  knot  slipping 
than  with  a  smaller  strand.  It  must  be  recognized,  however,  that  a  very  small 
strand  may  not  stand  the  strain  of  the  pulsation  of  the  vessel  or  may  tend  to 
cut  through  the  vessel  w^alls. 

Tw^o  ligatures  should  always  be  placed  at  a  distance  of  about  one-fourth 
of  an  inch  from  each  other.  This  consumes  but  little  more  time  and  adds 
greatly  to  the  safety.    If  only  one  ligature  is  passed  there  is  constant  pounding 


100  OPERATIVE    SURGERY 

upon  it  by  the  impact  of  the  arterial  current  and  healing  is  consequently  more 
difficult.  When  two  ligatures  are  placed,  the  one  nearest  the  heart  takes 
up  the  strain  of  the  arterial  impulse,  while  the  tissues  within  the  grasp  of  the 
second  ligature  can  heal  more  readily  because  they  are  at  rest  and  freed  from 
the  constant  pounding  of  the  heart.  Then,  too,  if  the  first  ligature  should  loosen 
it  will  at  least  probably  hold  long  enough  for  a  clot  to  form  between  the  two 
ligatures  and  this  clot  will  act  as  a  buffer  between  the  impulse  of  the  arterial 
current  and  the  second  ligature  and  so  reduce  the  strain  on  the  second  ligature. 
(Fig.  53.) 

In  tying  the  ligature  and  in  all  manipulations  of  the  artery  it  is  important 
to  move  the  artery  from  its  bed  as  little  as  possible.  This  is  true  of  all  vessels, 
but  it  is  particularly  important  when  the  vessels  are  diseased,  as  the  slightest 
interference  with  the  nutrition  of  the  wall  of  a  diseased  vessel  may  result  in 
secondary  hemorrhage.  The  Avound  should  be  closed  as  after  any  operation,  so 
as  to  eliminate  as  far  as  possible  dead  spaces  but  not  to  place  too  great  a  bur- 
den upon  the  tissues  by  unnecessary  suturing. 

An  artery  should  be  tied  as  far  as  possible  from  a  large  branch  or  else  the 
branch  should  be  ligated  also. 

If  a  large  arterial  trunk  of  an  extremity  is  ligated  the  limb  should  be 
wrapped  in  an  abundance  of  cotton  and  slightly  elevated  so  as  to  favor  the 
return  venous  flow  and  consequently  prevent  passive  congestion. 

LIGATION  OF  THE  INNOMINATE  ARTERY 

This  artery  is  sometimes,  though  very  rarely,  ligated  for  aneurism.  It  is 
the  largest  branch  of  the  arch  of  the  aorta  and  is  about  two  inches  in  length. 
It  rises  opposite  the  fourth  dorsal  vertebra,  runs  upward,  forward,  to  the  right, 
and  divides  into  the  right  common  carotid  and  the  right  subclavian.  It  termi- 
nates on  a  level  with  the  upper  border  of  the  right  sternoclavicular  articulation. 
In  front  of  this  artery  are  the  manubrium  with  the  muscles  that  arise  from  this 
bone,  the  right  sternoclavicular  joint,  the  remains  of  the  thymus  gland,  the  left 
innominate  vein,  the  right  inferior  thyroid  vein  and  the  lower  cervical  branches 
of  the  right  vagus  to  the  heart.  Posterior  are  the  trachea  and  right  pleura.  To 
the  right  are  the  right  innominate  vein,  the  right  vagus  nerve  and  the  right 
pleura.  To  the  left  are  the  left  common  carotid,  the  remains  of  the  thymus 
gland,  the  left  inferior  thyroid  vein  and  the  trachea. 

There  are  several  operations  for  tying  the  innominate  artery.  One  is  by 
'the  angular  incision  of  Mott,  Avhich  is  made  along  the  upper  margin  of  the 
clavicle,  the  sternomastoid  muscle  being  cut,  and  another  incision  from  the 
inner  end  of  this  goes  upward  about  three  inches  along  the  anterior  border  of 
the  sternomastoid.  An  excellent  approach  can  be  obtained  by  an  oblique  incis- 
ion along  the  lower  part  of  the  anterior  border  of  the  sternomastoid  which  is 
carried  over  on  the  manubrium.  The  common  carotid  is  exposed  and  followed 
down  to  the  clavicle  and  then  a  portion  of  the  manubrium  may  be  divided  or 
resected.    A  sufficient  amount  of  the  bone  is  taken  away  in  order  to  give  a  sat- 


LIGATION    OF    BLOOD   VESSELS  101 

isfaetoi'v  exposiii'c.  II  has  Ix'cii  ])r()p()S(Ml  to  si)lii  the  luamihi-imii  and  paii:  of 
the  sternuiu  with  a  saw,  protecting  the  tissues  beneath  1)y  a  flat  retractor, 
slipped  under  tlie  l)one.  The  important  point  is,  first  to  recognize  the  com- 
mon carotid  and  then  follow  down  to  the  innominate.  It  is  best  to  tie  bolli 
the  common  carotid  and  the  vertebral  artery  after  tying  the  innominate  in 
order  to  avoid  secondary  hemorrhage  and  to  reduce  the  circulation  in  the  aneu- 
rism as  much  as  possible. 

LIGATION  OF  THE  COMMON  CAROTID  ARTERY 

The  right  common  carotid  is  about  three  and  three  quarter  inches  in 
length  and  arises  from  the  innominate  artery.  It  contains  in  its  sheath  the 
internal  jugular  vein,  which  lies  to  the  outer  side,  and  the  vagus  nerve,  which 
lies  between  and  behind  the  artery  and  the  vein.  The  omohyoid  muscle  crosses 
the  common  carotid  and  the  portion  of  the  artery  below  the  omohyoid  muscle 
is  deeper  than  the  portion  above  it. 

The  left  common  carotid  is  longer  than  the  right,  being  about  four  and  one- 
half  inches  long,  and  arises  from  the  middle  of  the  arch  of  the  aorta  and  courses 
upward  and  outward.  It  is  overlapped  by  the  left  lung  and  pleura  in  its  first 
portion.  The  omohyoid  muscle  crosses  on  the  left  side  as  on  the  right.  The 
left  common  carotid  has  in  its  deep  portion  in  front,  the  manubrium  with  the 
muscles  that  arise  from  this  bone,  the  remains  of  the  thymus  and  the  left  in- 
nominate vein.  Behind  the  left  common  carotid  in  the  chest  are  the  trachea, 
esophagus,  the  thoracic  duct,  and  the  recurrent  laryngeal  nerve.  To  the  left 
are  the  pleura  and  lung,  the  left  vagus  nerve  and  the  left  subclavian  artery. 
Internally  are  the  innominate  artery,  the  trachea,  remains  of  the  thymus  gland 
and  the  inferior  thyroid  vein.  In  the  neck  both  common  carotids  have  a  similar 
relation,  being  covered  by  skin,  platysma,  fascia,  the  neck  muscles  that  arise 
from  the  sternum,  the  anterior  jugular  vein  and  several  superficial  veins,  which 
are  sometimes  irregular,  as  well  as  the  lingual  and  facial  veins  as  they  course 
across  the  artery.  In  front  also  is  the  descending  branch  of  the  hj'-pogiossal  nerve. 
Behind  are  the  vagus  nerve,  the  sympathetic  nerves  and  the  cervical  branches 
of  the  sympathetic  to  the  heart,  the  recurrent  laryngeal  nerve,  the  inferior 
thyroid  artery  and  the  deep  muscles  of  the  neck,  the  longus  colli  and  the  rectus 
capitis  anticus  major.  Externally  are  the  internal  jugular  vein  and  the  vagus 
nerve.  Internalhj,  is  the  trachea  below,  then  come  the  esophagus,  recurrent 
laryngeal  nerve,  branches  of  the  inferior  thyroid  artery,  the  thyroid  gland,  the 
larynx  and  the  lower  part  of  the  pharynx. 

The  line  of  the  common  carotid  artery  can  best  be  expressed  by  a  line 
drawn  from  a  23oint  just  external  to  the  sternoclavicular  articulation  to  a 
point  about  the  middle  of  a  line  between  the  angle  of  the  jaw  and  the  tip  of 
the  mastoid  process.  The  first  portion  of  this  line  as  high  as  the  upper  border 
of  the  thyroid  cartilage  represents  the  common  carotid.  Normally  there  are 
no  branches  from  the  common  carotid  except  the  terminal  branches.  If  the 
common  carotid  is  to  be  ligated  below  the  omohyoid  muscle  an  incision  about 


102  OPERATIVE   SURGERY 

three  and  one-half  inches  in  length  is  made  in  the  line  of  the  artery  from  just 
below  the  larynx  to  the  sternoclavicular  articulation.  After  cutting  through 
the  skin,  fascia  and  platj^sma,  the  superficial  veins  that  are  encountered  are 
pushed  aside  or  doubly  clamped  and  divided.  The  deep  fascia  is  incised  along 
the  anterior  border  of  the  sternomastoid,  which  is  retracted  outward.  The 
sternohyoid  muscle  is  either  retracted  inward  or  divided.  The  inferior  thyroid 
veins  are  doubly  clamped  and  tied.  The  sheath  of  the  artery  is  then  exposed. 
The  recurrent  laryngeal  nerve  which  lies  to  the  inner  side  must  be  guarded 
against  as  well  as  the  vagus  nerve  and  the  internal  jugular,  or  the  outer  side. 
Above  the  omohyoid,  an  incision  of  about  three  and  one-half  inches  in 
length  is  made  along  the  anterior  border  of  the  sternomastoid  muscle  with  its 
center  on  the  level  of  the  cricoid  cartilage.  Superficial  veins  are  retracted  or 
clamped  and  divided.  The  anterior  jugular  and  facial  veins  should  be  looked 
after.  They  are  of  considerable  size  and  are  doubly  clamped  or  tied  and  di- 
vided. The  sternomastoid  muscle  is  retracted  outward  and  the  omohyoid  down- 
ward and  inward,  or  the  omohyoid  may  be  divided.  The  sheath  of  the  artery  is 
carefully  cleared  and  divided  from  the  inner  side  to  avoid  the  descending 
branch  of  the  hypoglossal  nerve  and  the  internal  jugular  vein.  Ligatures 
should.be  passed  from  the  internal  jugular  vein  inward   (Fig.  54). 

LIGATION  OF  THE  EXTERNAL  CAROTID  ARTERY 

The  external  carotid  artery  is  the  smaller  of  the  two  terminal  divisions 
of  the  common  carotid  and  is  about  two  and  one-half  inches  in  length.  It 
lies  behind  the  upper  part  of  the  line  of  the  common  carotid  artery  and 
terminates  in  the  substance  of  the  parotid  gland,  just  in  front  of  the  ex- 
ternal auditory  meatus,  where  it  divides  into  the  internal  maxillary  and  the 
temporal  arteries. 

The  important  structures  in  front  of  this  artery  are  the  anterior  border 
of  the  sternomastoid  muscle,  the  hypoglossal  nerve,  the  lingual  and  facial 
veins,  the  posterior  belly  of  the  digastric  muscle,  and,  higher  up,  the  branches 
of  the  facial  nerve  and  the  carotid  gland.  Externallj',  besides  these  structures, 
is  the  internal  carotid  artery.  Behind  are  the  internal  carotid  artery,  the 
styloglossus  muscle,  the  glossoi^haryugeal  nerve,  and  the  pharyngeal  branches 
of  the  vagus  and  the  superior  laryngeal  nerve.  Jnternalhj  are  the  hyoid  bone 
and  the  pharynx,  the  submaxillary  gland,  the  parotid  gland,  and  the  ramus 
of  the  inferior  maxilla. 

It  is  well  known  that  the  Ijranches  of  tlie  external  carotid  are  irregular. 
It  was  formerly  considered  that  they  were  so  irregular  that  ligation  of  this 
artery  should  not  be  undertaken.  John  A.  AVyeth,  of  New  York,  in  a  series  of 
brilliant  dissections  proved  that  this  was  not  true,  but  that  the  variations  of  these 
branches  were  definite  and  according  to  regular  laws,  and  that  ligation  of  the  ex- 
ternal carotid  could  be  safely  undertaken.  Before  he  established  these  facts  it 
was  customary  to  ligate  the  common  carotid  when  tying  the  external  carotid 
seemed  indicated. 


LIGATION    OF    BLOOD    VESSELS 


103 


This  artery  may  l)e  ligated  either  above  or  below  tlic  digasti-ic  muscle, 
tlie  iilaee  of  election  being  below  the  digastric.  An  incision  is  made  about 
three  inches  long  just  behind  the  anterior  border  of  the  sternomastoid  mus- 
cle and  from  the  level  of  the  middle  of  the  thyroid  cartilage  to  near  the 
angle  of  the  jaw.  If  the  sternomastoid  muscle  is  large,  approach  to  the 
artery  is  made  easier  by  splitting  the  fibers  of  the  muscle  and  so  going  di- 
rectly down  to  the  artery.  If  the  sternomastoid  muscle  is  small  it  can  be 
readily  retracted  outward.  The  posterior  belly  of  the  digastric  is  seen  at 
the  upper  angle  of  the  wound  and  then  the  hypoglossal  nerve,  crossing  the  ex- 


Fig.    54. — Ligation    of    the    common    carotid,    external    carotid,    and    the    first    four    branches    of    the    external 
carotid.     If  the  common  carotid  is  to  be  tied  permanently,  two  ligatures  should  be  placed. 


ternal  carotid.  The  thyroid,  lingual  and  facial  veins  should  be  avoided,  but 
if  too  much  in  the  way,  they  may  be  doubly  clamped  and  tied.  The  liga- 
tures should  be  placed  below  the  superior  thyroid.  When  tying  the  external 
carotid,  it  is  best  to  ligate  at  the  same  time  the  superior  thyroid,  the  lingual 
artery  and  other  accessible  branches  of  the  external  carotid  as  the  collateral 
circulation  is  very  abundant.  Through  the  same  incision,  continued  slightly 
upward,  the  external  carotid  may  be  tied  above  the  digastric  muscle,  though 
this  ligation  is  rarely  indicated  (Fig.  54). 


104 


OPERATIVE    SURGERY 


LIGATION  OF  THE  SUPERIOR  THYROID 

The  superior  thyroid  artery  is  ligatecl  for  the  therapeutic  effect  on  the 
thyroid  giaiid  in  hyperthyroidism.  It  has  been  found  that  the  best  results 
are  obtained  by  ligating  this  artery  and  its  branches,  as  Avell  as  the  venous 
branches  at  the  upper  pole  of  the  thyroid  gland  just  as  it  disappears  into 
this  gland.  The  incision  for  this  ligation  is  a  transverse  incision,  if  possi- 
ble in  a  natural  crease  of  the  neck,  about  two  inches  long  and  on  a  level 
with  the  central  part  of  the  thyroid  cartilage.  The  level  of  this  incision  is 
affected  to  some  extent  by  the  size  of  the  thyroid  gland.  When  the  gland 
is  large  the  incision  should  be  made  at  a  higher  level.  If  both  superior 
thyroid  arteries  are  to  be  tied  at  the  same  sitting,  an  incision  about  three 
inches  long  is  made  across  the  larynx  on  the  level  with  the  middle  of  the 


Fig.    55. — Ivigation    of   the    superior   thyroid   artery.      In   the   actual    operation    the    incision    is    only    about   two 
inches  long  unless  both  superior  thyroids  are  to  be  tied  at  the  same  operation,  as  shown  in  this  drawing. 


thyroid  cartilage,  with  its  center  in  the  midline  of  the  neck.  The  inner 
border  of  the  sternomastoid  muscle  is  retracted  outward  which  exposes  the 
omohyoid  muscle.  This  muscle  is  rather  deep  and  dissection  for  it  had  best 
be  done  bluntly  by  inserting  the  scissors  closed  and  opening  them  so  as  to 
stretch  the  tissues  apart.  When  the  omohyoid  is  well  identified  it  is  re- 
tracted inward,  retracting  also  the  sternomastoid  outward.  This  exposes 
the  terminal  branches  of  the  superior  thyroid  artery  along  with  the  upper  pole 
of  the  thyroid  gland.  These  branches  are  surrounded  by  a  ligature,  pref- 
erably linen  or  silk,  as  catgut  in  hyperthyroid  patients  might  be  absorbed 
too  soon.  The  ligature  is  tied  as  closely  as  possible  to  the  upper  pole  of 
the  thyroid  gland.  It  is  probably  better  to  place  a  second  ligature  a  short 
distance  from  the  first  one.  The  technic  of  this  operation  has  been  developed 
by  C.  H.  Mayo  (Fig.  55). 


LIGATION    OP    BLOOD   VESSELS  105 

LIGATION  OF  THE  INTERNAL  CAROTID  ARTERY 

The  internal  carotid  is  li<>ated  tliroii<>li  an  incision  similar  to  that  nsed 
in  lig-ating  the  external  carotid,  except  that  it  may  ])e  placed  slightly  farther 
externally.  The  bifurcation  of  the  common  carotid  is  identitied  and  the 
external  carotid  exposed  and  identified  by  its  location  and  by  its  branches. 
The  internal  carotid  does  not  give  off  branches  in  the  neck.  The  internal 
carotid  at  its  origin  is  slightly  external  to  the  external  carotid  and  then 
sinks  more  deeply  in  the  neck.  It  is  tied  near  its  origin,  the  ligature  being 
passed  from  the  side  of  the  internal  jugular  vein,  care  being  taken  to  avoid 
this  vein,  the  vagus  nerve,  and  the  ascending  pharyngeal  artery  (Fig.  54). 

LIGATION  OF  THE  SUBCLAVIAN  ARTERY 

The  subclavian  artery  is  usually  ligated  in  its  third  portion  but  sometimes 
in  its  first  part.  The  ligation  of  the  first  part  of  the  subclavian  carries  a 
high  mortality. 

The  subclavian  on  the  right  side  arises  from  the  innominate  and  is  about 
three  inches  in  length,  whereas  on  the  left  side  it  arises  from  the  arch  of  the 
aorta  and  is  one  inch  longer.  It  is  divided  into  three  portions,  the  first 
portion  extending  from  its  origin  to  the  internal  border  of  the  scalenus  an- 
ticus  muscle.  On  the  right  side  this  part  is  about  one  and  one-fourth  inches 
long  and  on  the  left  side  tAvo  and  one-quarter  inches  long.  The  important 
structures  in  front  of  the  first  portion  on  the  right  side  are  the  sternomastoid 
muscle  and  the  sternohyoid  and  sternothyroid  muscles,  the  right  innominate  vein, 
the  internal  jugular  vein,  the  vagus  and  phrenic  nerves,  and  the  superior  cardiac 
branches  of  the  sympathetic  nerve.  Behind  are  the  sympathetic  nerves,  the  infe- 
rior cardiac  nerve,  and  the  recurrent  laryngeal  nerve,  the  longus  colli  muscle, 
the  transverse  process  of  the  seventh  cervical  and  the  first  dorsal  vertebra,  the 
apex  of  the  right  lung,  the  pleura,  and  the  neck  of  the  first  rib.  Below  are  the 
pleura  and  lung,  the  recurrent  laryngeal  nerve,  and  the  subclavian  vein.  On  the 
left  side  the  first  portion  of  the  subclavian  is  much  longer  than  on  the  right,  but 
the  relations  are  much  the  same  as  of  the  first  portion  of  the  right  subclavian, 
except  that  the  thoracic  duct  and  the  subclavian  vein  are  in  front  and  the  com- 
mon carotid  artery  is  in  front  and  the  trachea,  the  recurrent  laryngeal  nerve, 
the  left  common  carotid,  the  esophagus  and  the  thoracic  duct  are  internal.  The 
second  portion  of  both  subclavian  arteries  is  about  three-fourths  of  an  inch 
long  and  lies  behind  the  scalenus  anticus  muscle,  which  separates  the  subclavian 
artery  from  the  subclavian  vein.  Both  the  first  and  the  second  portion  of  the 
artery  are  overlapped  by  the  sternomastoid  muscle.  The  phrenic  nerve  crosses 
obliquely  the  lower  anterior  surface  of  the  scalenus  anticus  muscle.  The  second 
portion  of  the  left  subclavian  is  very  rarely  ligated.  The  third  portion  of  the 
subclavian  is  the  part  that  is  chosen  for  ligature  if  the  circumstances  will  per- 
mit. This  lies  in  the  subclavian  triangle  whose  borders  are  the  sternomastoid, 
the  outer  belly  of  the  omohyoid  and  the  clavicle.     The  important  structures 


106 


OPERATIVE    SURGERY 


in  front  of  the  third  portion  of  the  subclavian  are  some  branches  of  the  cervical 
plexus,  the  suprascapular  artery,  the  external  jugular  vein  and  its  communica- 
tions, together  with  the  suprascapular  and  transversalis  colli  vein  and  the 
clavicle.  Behind  are  the  scalenus  medius  muscle  and  the  lowest  cord  of  the 
brachial  plexus.  Atove  are  the  brachial  plexus  and  the  omohyoid,  and  helow 
is  the  first  rib.  The  subclavian  artery  terminates  at  the  lower  border  of  the 
first  rib. 

The  ligation  of  the  first  portion  of  the  subclavian  can  be  done  by  the 
same  angular  incision  that  is  used  for  exposing  the  innominate.  An  in- 
cision is  made  along  the  anterior  border  of  the  sternomastoid  muscle  about 
three  and  one-half  inches  long  and  terminates  at  the  right  sternoclavicular 
joint.  This  is  joined  at  its  lower  end  by  an  incision  of  about  three  and  one-half 
inches  along  the  upper  border  of  the  clavicle.     The  sternomastoid  muscle  and 


Ligation   of    the   subclavian   artery. 


sternothyroid  and  sternohyoid  muscles  are  divided  near  the  clavicle  aud  the 
common  carotid  is  exposed.  The  common  carotid  is  traced  down  to  the 
bifurcation  of  the  innominate  artery.  The  pleura  is  protected  and  pushed 
downward.  The  internal  jugular  vein  and  the  vagus  nerve  are  retracted 
either  inward  or  outward,  depending  upon  which  appears  to  afford  the 
best  access  to  the  site  of  the  ligature.  The  ligatures  are  passed  from  below. 
It  is  safer  to  secure  the  vertebral  artery  and  the  common  carotid  at  the  same 
time. 

The  third  portion  of  the  subclavian  artery  is  ligated  by  making  an  in- 
cision about  four  inches  long  over  the  clavicle,  first  drawing  the  skin  down 
and  cutting  dowai  on  the  clavicle,  beginning  the  incision  from  the  posterior 
border  of  the  sternomastoid  muscle.  "When  the  skin  is  relaxed  the  incision 
will  be  found  to  be  about  one-half  inch  above  the  clavicle.  The  margins 
of  the   sternomastoid   and   trapezius   muscles   are   identified   and   divided  if 


LIGATION    OF    BLOOD   VESSELS  107 

necessary.  Tlie  external  jugular  vein  is  retracted  or  d()ul)]y  divided  and  the 
veins  Avliicli  empty  into  the  external  jugular,  as  well  as  the  subscapular  and 
transversalis  colli  veins  are  divided  or  retracted.  The  transversalis  colli  and 
the  suprascapular  artery  usually  run  near  the  field  but  they  should  be  carefully 
preserved  if  possible  for  collateral  circulation.  The  outer  margin  of  the 
scalenus  anticus  muscle,  which  lies  just  under  the  sternomastoid  muscle,  is 
identified  and  followed  down  to  the  artery.  The  lowest  cord  of  the  brachial 
plexus  is  exposed  and  the  subclavian  vein  which  lies  in  front  of  and  below  the 
artery.  The  pleura  must  also  be  guarded.  The  sheath  is  opened  and  the 
ligature  passed  from  the  brachial  plexus,  avoiding  the  pleura  and  the  sub- 
clavian vein  (Fig.  56). 

LIGATION  OF  THE  VERTEBRAL  ARTERY 

The  vertebral  artery  sometimes  requires  ligation  and  it  should  be  tied 
if  there  is  occasion  to  ligate  the  subclavian  in  its  first  branch.  The  vertebral 
is  the  largest  and  usually  the  first  branch  of  the  subclavian  and  is  exposed 
by  the  same  incision  as  would  be  used  in  ligating  the  common  carotid  in  its 
first  portion.  After  exposing  the  sheath  of  the  common  carotid  this  vessel 
with  the  internal  jugular  vein  and  the  vagus  nerve  is  retracted  outward 
and  the  prevertebral  fascia  is  cut  vertically  just  below  the  transverse  proc- 
ess of  the  sixth  cervical  vertebra.  A  short  distance  below  this  point  the 
vertebral  is  crossed  by  the  inferior  thyroid  artery.  The  vertebral  artery 
should  be  tied  a  short  distance  below  the  transverse  process  of  the  sixth 
cervical,  where  the  artery  enters  the  foramen  in  this  vertebra.  The  inferior 
thyroid  artery  and  the  recurrent  laryngeal  nerve  are  retracted  to  the  inner 
side  and  doAvnward  and  the  outer  structures  are  retracted  outward. 

LIGATION  OF  THE  INFERIOR  THYROID  ARTERY 

In  ligating  this  artery  the  first  portion  of  the  common  carotid  should 
be  exposed  as  though  it  were  to  be  ligated.  A  vertical  or  a  transverse  in- 
cision in  the  skin  is  made.  The  transverse  incision  is  half  of  the  ''collar" 
incision  for  thyroidectomy.  Below  the  omohyoid  muscle  the  carotid  artery 
in  its  sheath  is  retracted  outward  and  the  tendon  of  the  omohyoid  muscle  is 
pulled  upAvard  while  the  thyroid  gland  and  trachea  are  retracted  inward. 
The  inferior  thyroid  artery  will  be  seen  opposite  the  carotid  tubercle,  which 
is  the  transverse  process  of  the  sixth  cervical  vertebra.  The  inferior  thy- 
roid artery  runs  behind  the  common  carotid  artery  at  about  the  same  level 
as  the  omohyoid  tendon  crosses  in  front  of  the  common  carotid.  The  in- 
ferior thyroid  is  ligated  as  far  as  possible  from  the  thyroid  gland  so  as  to 
avoid  injuring  the  recurrent  laryngeal  nerve,  which  runs  behind  the  thy- 
roid gland.  This  nerve  and  the  middle  cervical  sympathetic  ganglion  should 
be  carefuUv  avoided. 


108  OPERATIVE    SURGERY 

LIGATION   OF   THE   AXILLARY  ARTERY 

The  axillary  artery  is  a  continuation  of  the  subclavian  and  begins  at 
the  lower  border  of  the  first  rib  and  ends  at  the  lower  border  of  the  tendon 
of  the  teres  major  muscle,  where  it  becomes  the  brachial.  The  axillary  ar- 
tery is  divided  into  three  parts  by  the  tendon  of  the  pectoralis  minor  muscle, 
which  covers  the  middle  or  the  second  part  of  the  artery.  The  first  part  of 
the  artery,  which  extends  from  the  lower  border  of  the  first  rib  to  the  upper 
border  of  the  pectoralis  minor,  has  in  front  the  major  pectoral  muscle,  the 
cephalic  vein,  the  external  anterior  thoracic  nerve,  together  with  lymphatic 
trunks.  Behind  are  the  posterior  thoracic  nerve  and  the  first  intercostal  space. 
Externally  is  the  brachial  plexus,  and  interndlij  is  the  internal  anterior  thoracic 
nerve.  The  second  part  which  lies  behind  the  pectoralis  minor  muscle,  has 
posteriorly  the  posterior  cord  of  the  brachial  plexus  and  externally  the  exter- 
nal cord,  while  internally  are  the  internal  cord  of  the  brachial  plexus  and  the 
axillary  vein.  The  second  part  is  about  one  and  a  quarter  inches  in  length. 
The  third  part  which  is  the  longest,  and  is  three  inches  in  length,  ex- 
tends from  the  border  of  the  pectoralis  minor  to  the  lowest  border  of 
the  tendon  of  the  teres  major.  In  front  are  the  pectoralis  major  muscle 
and  the  inner  root  of  the  median  nerve,  as  well  as  an  external  brachial  vein. 
Behind  are  the  musculospiral  nerve,  the  circumflex  nerve  and  the  subscapularis, 
the  latissimus  dorsi  and  teres  major  muscles.  Externally  are  the  outer  root 
of  the  median  nerve,  the  musculocutaneous  nerve  and  the  coracobrachialis 
muscle.  Internally  are  the  inner  root  of  the  median  nerve,  the  ulnar  nerve,  the 
internal  cutaneous  nerves  and  the  axillary  vein. 

The  part  of  the  axillary  artery  usually  ligated  is  the  third  part.  When 
ligation  of  the  first  part  seems  indicated  it  is  usually  best  to  tie  the  third 
part  of  the  subclavian.  Ligation  of  the  first  part,  however,  can  be  done  by 
an  incision  below  the  clavicle  extending  from  near  the  outer  portion  of  the 
sternoclavicular  joint  to  the  coracoid  process  of  the  scapular.  The  branches 
of  the  acromial  thoracic  artery  should  be  carefully  protected  on  account 
of  collateral  circulation.  The  major  pectoral  muscle  is  divided  and  the 
branches  of  the  anterior  thoracic  nerve  with  the  veins  in  its  neighborhood 
are  retracted  upward  and  outward.  The  artery  here  lies  between  the  axil- 
lary vein  on  the  inner  side  and  the  brachial  plexus  on  the  outer  side. 

The  third  part  of  the  axillary  artery  is  ligated  by  an  incision  about  three 
inches  long,  which  begins  at  the  front  part  of  the  apex  of  the  inner  wall  of 
the  axilla  and  passes  outward  and  downward  along  the  inner  border  of 
the  coracobrachialis  muscle,  the  arm,  of  course,  being  extended  and  elevated. 
The  coracobrachialis  muscle  and  the  musculocutaneous  nerve  are  retracted 
out  along  with  the  median  nerve.  The  internal  cutaneous  and  ulnar  nerves 
are  retracted  inward.  Yenge  comites  are  generally  present  at  this  portion, 
as  well  as  occasionally  the  basilic  vein.  The  axillary  A'ein  alone  may  be 
present  at  the  inner  side  of  the  artery  if  it  does  not  form  farther  in.  The 
ligatures  should  be  passed  from  the  side  of  the  A'ein. 


LIGATION    OF    BLOOD   VESSELS  109 

LIGATION  OF  THE  BRACHIAL  ARTERY 

The  brachial  artery  extends  i'rom  the  beginuiiig'  of  the  axillary,  at  the 
lower  border  of  the  tendon  of  the  teres  major  muscle,  to  about  opposite  the 
neck  of  the  radius.  The  chief  relations  are  anteriorly,  the  median  nerve 
in  the  middle  course  of  the  artery ;  posteriorly,  in  the  upper  portion  of  the 
artery  the  musculospiral  nerve,  then  the  superior  profunda  artery  and  the 
inner  head  of  the  triceps  muscle,  the  insertion  of  the  coracobrachialis  muscle, 
and  the  brachialis  anticus  muscle.  Externally  are  the  coracobrachialis,  which 
slightly  overlaps  the  artery  and  the  median  nerve  above,  and  the  belly  of  the 
biceps,  which  also  slightly  overlaps  the  artery.  Internally  are  the  internal 
cutaneous  and  ulnar  nerves  above  and  the  median  nerve  below.  The  cephalic 
vein  is  constantly  internal,  as  well  as  the  one  of  the  venae  comites. 

The  middle  of  the  arm  is  the  elective  point  for  ligation  of  the  brachial 
artery  and  the  course  of  the  artery  is  indicated  by  a  line  from  the  junction 
of  the  anterior  and  middle  thirds  of  the  outer  wall  of  the  axilla  to  the 
center  of  the  bend  of  the  elbow.  An  incision  about  three  inches  long  is 
made  with  its  center  about  opposite  the  middle  of  the  arm  and  extending 
along  the  inner  border  of  the  biceps  muscle  in  the  line  of  the  artery.  The 
belly  of  the  biceps  must  be  recognized  and  retracted  outward.  The  median 
nerve  crosses  the  front  of  the  artery  about  the  middle  of  this  incision  and  the 
internal  cutaneous  nerve  is  on  the  inner  side  of  the  artery. 

If  the  patient  has  a  well  developed  biceps  muscle  it  is  sometimes  rather 
difficult  to  expose  the  artery  unless  the  biceps  is  well  retracted. 

LIGATION  OF  THE  RADIAL  AND  ULNAR  ARTERIES 

There  is  practically  no  occasion  to  ligate  the  radial  artery  except  just 
above  the  wrist  when  there  is  an  injury  to  one  of  the  palmar  arches.  The 
two  palmar  arches,  deep  and  superficial,  anastomose  so  freely  that  when  there 
is  a  serious  injury  to  either  of  these  arches  it  is  best  to  ligate  both  the  radial 
and  the  ulnar  arteries  at  the  wrist,  though  sometimes  the  ligation  of  the 
radial  artery  alone  will  control  the  deep  palmar  arch,  which  is  a  contin- 
uation of  the  radial  artery;  or  ligation  of  the  ulnar  artery  alone  will  con- 
trol the  superficial  palmar  arch,  which  is  a  continuation  of  the  ulnar 
artery.  The  lower  portion  of  the  radial  artery  in  the  forearm  is  covered  only 
by  skin  and  fascia  in  front,  and  behind  are  the  pronator  quadratus  and  the 
anterior  surface  of  the  lower  end  of  the  radius.  Externally  the  radial  nerve 
is  at  some  distance  from  the  artery  in  the  lower  part  of  the  forearm.  The 
tendon  of  the  brachioradialis  lies  to  the  outer  side  of  the  artery  and  is  inserted 
into  the  radius  external  to  the  superficial  portion  of  the  radial  artery  in  the 
lower  part  of  the  forearm. 

An  incision  about  two  inches  long  is  made  over  the  artery  in  the  lower 
part  of  the  front  of  the  forearm,  extending  from  the  wrist  upward.  The  artery 
is  superficial  here  and  can  easily  be  felt.    It  is  accompanied  by  two  veins,  which 


110  OPERATIVE    SURGERY 

should  be  dissected  free  as  the  tissues  along  these  veins  often  contain  small 
nerves.  In  the  upper  portion  of  the  incision,  the  tendon  of  the  brachioradialis 
will  be  to  the  outer  side  and  the  tendon  of  the  flexor  carpi  radialis  will  be 
to  the  inner  side.  The  artery  is  accompanied  by  a  small  branch  of  the  musculo- 
cutaneous nerve,  which  should  be  avoided. 

The  ulnar  artery  is  ligatcd  in  the  lower  part  of  the  forearm  on  about  the 
same  level  as  the  radial  artery.  It,  too,  is  largely  superficial  at  this  point, 
being  covered  only  by  skin  and  fascia.  Some  cutaneous  branches  of  the  ulnar 
nerve  are  in  front.  Internally  is  the  tendon  of  the  tlexor  carpi  ulnaris,  and 
externally,  to  the  radial  side,  are  the  tendons  of  the  flexor  sublimis  digitorum. 
The  low^er  portion  of  the  artery  corresponds  to  a  line  drawn  from  the  anterior 
portion  of  the  internal  condyle  of  the  humerus  to  the  radial  side  of  the  pisiform 
bone.  An  incision  is  made  about  two  inches  long  beginning  at  the  pisiform 
bone  and  extending  upward.  The  tendon  of  the  flexor  carpi  ulnaris  is  retracted 
inward  and  if  necessary  the  tendons  of  the  flexor  sublimis  digitorum  are  re- 
tracted outward,  though  usually  they  are  not  in  the  way.  The  artery  lies  upon 
the  flexor  profundus  digitorum  and  is  closely  surrounded  by  venfe  comites. 
The  ulnar  nerve  is  in  close  relation  to  the  inner  side  of  the  artery. 

LIGATION  OF  THE  ABDOMINAL  AORTA 

Ligation  of  the  aorta  in  the  abdomen  is  hardly  a  justifiable  operation, 
in  view  of  the  fact  that  of  the  twenty  cases  that  have  been  ligated  all  have 
proved  fatal.  One  patient  lived  forty-eight  days  (Keen).  It  may  be  possi- 
ble that  in  some  cases  with  a  markedly  sacculated  aneurism  the  neck  of  the 
aneurism  itself  could  be  clamped,  or  ligated,  or  a  rubber  tube  might  be  su- 
tured in  between  the  ends  of  the  resected  aorta  and  held  by  flaps  of  fascia 
lata.  Such  procedures,  however,  are  still  in  the  experimental  stage  and 
would  hardly  be  justified  at  present  on  the  human  body. 

The  technic  of  ligating  the  abdominal  aorta  in  its  lower  portion  would 
consist  in  making  a  median  abdominal  incision,  in  Trendelenburg  position, 
and  a  close  dissection  of  the  aorta  so  as  to  prevent  thejnclusion  of  sympa- 
thetic nerves  or  lym]3hatic  trunks. 

LIGATION  OF  THE  COMMON  ILIAC  ARTERY 

The  abdominal  aorta  bifurcates  opposite  the  lower  border  of  the  left  side 
of  the  fourth  lumbar  vertebra  about  one-half  inch  below  and  a  little  to  the 
left  of  the  umbilicus.  Its  two  branches,  the  common  iliacs,  pass  outward  and 
bifurcate  into  the  external  and  internal  iliac  arteries  about  opposite  the 
upper  border  of  the  sacroiliac  joint.  On  the  right  side,  the  common  iliac 
artery  near  its  termination  is  crossed  by  the  ureter  and  is  covered  with  peri- 
toneum and  subperitoneal  fascia.  Behind  are  the  right  common  iliac  vein, 
the  termination  of  the  left  common  iliac  vein,  and  the  beginning  of  the  in- 
ferior vena  cava.     Still  further  posteriorly  are  the  psoas  magnus  muscle  with 


LIGATION    OF    BLOOD   VESSELS  111 

tlic  obturator  nerve  and  the  iliolmnhar  arlery.  Exiern<(]hj  are  tlie  beginning 
of  the  lower  vena  cava,  the  end  of  the  right  common  iliac  vein,  and  the  psoas 
magnus  muscle.  Internally  are  the  right  common  iliac  vein  and  the  hypogastric 
])lexus.  On  the  left  side,  the  common  iliac  artery  has  near  its  termination 
in  front  the  ureter  and  tlie  ovarian  artery  in  the  female,  the  termination  of  the 
inferior  mesenteric  artery,  the  sigmoid  mesocolon,  and  the  superior  hemorrhoidal 
artery.  Posteriorly  are  the  lower  part  of  the  body  of  the  fourth  lumbar  vertebra, 
tlie  fifth  lumbar  vertebra  and  the  intervertebral  disc,  the  left  common  iliac 
vein,  the  psoas  magnus  muscle,  obturator  nerve  and  iliolumbar  artery.  Exter- 
iiaUy  is  the  psoas  muscle,  and  internally  are  the  left  common  iliac  vein,  the  hypo- 
gastric plexus  and  the  middle  sacral  arter}-. 

Tlie  right  common  iliac  is  about  two  inches  long  and  the  left  about  one 
and  three-quarters.  The  arteries  should  be  ligated  as  near  their  middle  as  pos- 
sible. Formerly,  when  the  danger  of  sepsis  was  great  it  was  thought  best  never 
to  open  the  peritoneum.  In  those  days  the  extraperitoneal  operation  of  Sir 
Astley  Cooper  Avas  employed  in  order  to  avoid  peritonitis.  This  danger  does 
not  now  exist.  The  common  iliacs,  as  well  as  the  internal  and  external  iliacs, 
can  best  be  tied  through  an  abdominal  incision  in  the  midline,  extending  from 
about  the  navel  to  the  pubes.  The  patient  should  be  put  in  the  Trendelenburg 
position  and  the  intestines  packed  away  out  of  the  pelvis,  affording  good  ex- 
posure. The  termination  of  the  abdominal  aorta  is  identified  and  the  common 
iliacs  are  located.  The  peritoneum  is  incised  over  the  middle  of  the  common 
iliac  and  the  ligature  is  passed  from  the  side  of  the  iliac  vein.  As  elsewhere, 
there  should  always  be  two  ligatures  placed  about  a  quarter  of  an  inch  to  a 
half  an  inch  from  each  other. 

LIGATION  OF  THE  INTERNAL  ILIAC  ARTERY 

The  internal  iliac  artery  is  about  one  and  one-half  inches  in  length  and 
arises  from  the  bifurcation  of  the  common  iliac  opposite  the  upper  part  of 
the  sacroiliac  joint.  The  important  relations  are,  anteriorly  the  ureter,  poste- 
riorly the  external  iliac  vein,  and  internally  the  internal  iliac  vein.  Behind 
is  also  the  obturator  nerve.  The  psoas  muscle  is  external.  This  artery,  which 
is  frequently  ligated  to  control  bleeding  in  cancer  of  the  uterus,  is  exposed 
by  the  same  incision  used  for  the  common  iliac.  The  bifurcation  of  the 
common  iliac  opposite  the  upper  border  of  the  sacroiliac  joint  should  be  lo- 
cated. The  ureter  is  identified  as  it  crosses  about  this  region.  On  the  left  side 
the  lower  part  of  the  sigmoid  makes  the  operation  slightly  more  complicated 
than  on  the  right  side.  On  the  right  side  the  peritoneum  can  be  divided  directly 
over  the  vessel.  An  incision  about  one  and  one-half  inches  long  is  made  through 
the  peritoneum,  the  ureter  identified  and  retracted  out  of  the  way,  and  the  bi- 
furcation of  the  common  iliac  and  its  two  branches,  the  external  and  internal 
iliacs,  are  thoroughly  identified.  The  fascia  over  the  internal  iliac  is  incised 
and  the  ligatures  are  passed  from  without  inward,  hugging  the  artery  close  to 
avoid  injury  to  the  external  iliac  vein  and  also  avoiding  injuring  the  internal  iliac 


112  OPERATIVE   SURGERY 

vein  that  lies  close  behind  and  to  the  internal  surface  of  the  artery.  On  the 
left  side  the  ligation  is  carried  out  in  the  same  manner  as  on  the  right,  except 
that  if  the  sigmoid  is  short  and  has  a  short  mesentery  it  will  be  necessary  to 


Fig.   57. — Ligation   of   the   internal   iliac   artery. 

pull  the  sigmoid  dov^^n  to  note  the  vessels  in  the  mesentery  so  as  to  avoid  them, 
and  make  an  incision  through  the  mesosigmoid  (Fig.  57). 

LIGATION  OF  THE  EXTERNAL  ILIAC  ARTERY 

The  external  iliac  artery  is  three  and  one-half  to  four  inches  in  length. 
It  arises  at  the  upper  border  of  the  sacroiliac  joint,  runs  outward,  and  ter- 
minates beneath  the  loAver  border  of  Poupart's  ligament.  The  external  iliac 
vein  lies  to  the  inner  side  of  the  artery  below  and  to  the  inner  side  and  be- 
hind above.  The  genital  branch  of  the  genitocrural  nerve  lies  in  front  of 
the  artery  over  its  lower  third.  It  is  crossed  by  the  spermatic  artery  and 
vein  in  the  male,  and  the  ovarian  artery  and  vein  in  the  female,  as  well  as 
by  the  vas  deferens  in  the  male  near  the  termination  of  the  artery.  At  this 
point  also  the  deep  epigastric  artery,  which  is  important  for  collateral  cir- 
culation, lies  in  front  of  the  vessel  and  adherent  to  the  peritoneum  as  it 
courses  forward  and  upward.  Behind  are  the  external  iliac  vein  and  the 
inner  border  of  the  psoas  magnus  muscle.     Externally  is  the  psoas  magnus 


LIGATION    OF    BLOOD   VESSELS  113 

muscle  with  the  nerves  it  contains.  The  external  iliac  artery  can  be  reached  by 
the  same  incision  by  which  the  common  and  internal  iliacs  are  reached,  or  if 
it  is  desired  to  ligate  this  artery  nearer  to  Ponpart's  ligament,  this  can  be  done 
either  by  a  mnscle  splitting  incision  or  by  the  extraperitoneal  operation  in  which 
an  incision  is  made  parallel  to  Ponpart's  ligament  and  about  half  an  inch 
above  it.  The  peritoneum  is  reached  and  stripped  up  and  the  external  iliac 
artery  is  exposed.  Care  should  be  taken  to  preserve  its  branches,  particularly 
the  deep  epigastric,  for  the  collateral  circulation.  Although  the  peritoneum 
is  not  opened  in  the  extraperitoneal  operation,  the  Trendelenburg  position 
is  a  great  help.  After  the  peritoneum  is  stripped  up  with  dry  gauze,  the 
sheath  of  the  external  iliac  is  opened  from  the  outer  side  to  avoid  the  vein 
Avhich  is  internal  to  the  artery.  Care  is  taken  to  avoid  injury  to  the  genito- 
crural  nerve.  A  ligature  is  passed  about  one  and  one-half  inches  above  Pon- 
part's ligament. 

LIGATION  OF  THE  FEMORAL  ARTERY 

The  femoral  artery  is  a  continuation  of  the  external  iliac  and  begins  at 
the  lower  border  of  Ponpart's  ligament  about  half  w^ay  between  the  anterior 
superior  spine  of  the  ilium  and  the  symphysis  pubis.  It  passes  down  the 
anterior  and  inner  side  of  the  thigh  to  the  junction  of  the  middle  and  lower 
thirds  of  the  thigh,  where  it  becomes  the  popliteal.  The  superficial  part  lies 
in  Scarpa's  triangle,  which  is  bound  externally  by  the  sartorious  muscle  and 
internally  by  the  adductor  longus  with  its  base  formed  by  Ponpart's  liga- 
ment. The  apex  of  Scarpa's  triangle  is  where  the  sartorius  crosses  the  adduc- 
tor longus.  The  lower  third  of  the  femoral  artery  passes  through  Hunter's 
canal,  which  is  an  aponeurotic  channel  that  extends  fro|iu  the  apex  of 
Scarpa's  triangle  to  the  opening  in  the  adductor  magnus.  The  common  fem- 
oral artery,  which  is  that  portion  from  the  origin  of  the  femoral  to  the 
origin  of  the  profunda  femoris,  is  about  one  and  a  half  inches  long.  The 
important  structures  in  front  are  the  crural  branch  of  the  genitocrural  nerve 
and  the  superficial  circumflex  iliac  vein.  Behind  are  the  psoas  and  pectineus 
muscles;  externally  is  the  anterior  crural  nerve,  and  internally  the  femoral 
vein.  The  relations  of  the  femoral  artery  from  the  origin  of  the  profunda 
femoris  to  the  apex  of  Scarpa's  triangle  are,  in  front,  the  crural  branch  of  the 
genitocrural  nerve  and  heJdnd,  the  femoral  vein,  profunda  vein,  and  profunda 
artery  in  the  order  named,  then  the  pectineus  muscle  and  the  adductor  longus. 
Externally  are  the  branches  of  the  anterior  crural  nerve,  the  long  saphenous 
nerve  and  the  nerve  to  the  vastus  internus,  and  internally  is  the  femoral  vein, 
which  becomes  posterior  at  the  apex  of  the  Scarpa's  triangle.  The  third  divi- 
sion of  the  femoral  artery  is  that  in  Hunter's  canal  where  it  is  deep.  Behind 
is  the  femoral  vein,  which- becomes  slightly  external  at  its  lower  portion;  heliind 
also,  are  the  vastus  internus  and  adductor  muscles.  Externally  is  the  vastus 
internus  and  internally  are  the  adductor  longus  above  and  the  adductor  magnus 
below. 


114 


OPERATIVE    STTRGERY 


The  favorite  point  for  ligation  of  the  femoral  is  at  the  apex  of  Scarpa's 
triangle,  which  is  called  the  operation  of  election.  The  apex  of  Scarpa's 
triangle  is  about  three  and  one-half  inches  below  Poupart's  ligament  and 
the  profunda  artery  arises  about  one  and  a  half  inches  below  Poupart's  liga- 
ment. At  the  apex  of  Scarpa's  triangle  the  relation  of  the  vessels  from  be- 
fore backward  is  the  femoral  artery,  femoral  vein,  profunda  vein,  profunda 
artery.  The  artery  lies  behind  a  line  drawn  from  a  point  about  midway  be- 
tween the  anterior  superior  spine  of  the  ilium  and  the  symphysis  pubis,  to  the 
tubercle  of  the  inner  condyle  of  the  femur. 

Ligation  of  the  common  femoral,  or  the  femoral  in  its  first  portion,  is 
considered  dangerous  because  of  the  former  frequency  of  secondary  hemor- 


Fig.   58. — Ligation   of   the   right   femoral   artery   just   below    Poupart's   ligament. 

rhage  and  because  of  the  danger  of  gangrene.  If  ligation  of  the  common 
femoral  seems  indicated  it  would  probably  be  safer  to  ligate  the  external  iliac. 
The  common  femoral  can  be  ligated  by  an  incision  about  three  inches 
long  beginning  just  above  Poupart's  ligament  and  extending  down  in.  the 
line  of  the  artery.  The  superficial  circumflex  iliac,  superficial  epigastric, 
and  superficial  external  pudic  vessels,  should  be  avoided,  also  the  crural 
branch  of  the  genitocrural  nerve,  Avhich  is  in  front  of  and  a  little  external  to 
the  artery.  The  anterior  crural  nerve  lies  further  to  the  outer  side  of  the 
artery  and  outside  of  the  sheath.  The  ligature  is  passed  from  the  inner 
side,  avoiding  injury  to  the  femoral  vein  (Fig.  58).  The  common  femoral  artery 
can  also  be  exposed  by  an  incision  parallel  to  Poupart's  ligament  and  about 
one-half  inch  below  it. 


1,1(!AT10N    OF    liLOOn    VE8SEI>S  115 

Lisi'ation  of  llie  femoral  at  tlic  point  of  election,  the  apex,  of  Scarpa's  tri- 
aiigie,  is  made  throu<ili  an  ineision  three  inches  in  length  in  the  line  of  the 
the  artery  with  the  center  of  the  incision  over  the  apex  of  Scarpa's  triangle, 
which  is  about  three  and  one-half  inches  helow  Poupart's  ligament.  First 
the  iuwor  margin  of  the  sartorius  nuisele  is  identified  and  retracted  outward,  and 
then  the  tissues  l)etwe(Mi  tlie  sartorius  and  the  adductor  longus  nuis(des  are 
dissected.  The  long-  saphenous  nerve  is  in  front  of  the  artery  and  is  re- 
tracted. The  femoral  vein  is  internal  and  posterior.  The  ligature  should 
be  passed  from  the  inner  side.  The  femoral  artery  is  l)ut  seldom  tied  in 
Hunter's  canal,  but  may  be  ligated  in  this  region  by  an  incision  about  four 
inches  long  over  the  line  of  the  lower  part  of  the  artery,  retracting  the  sar- 
torius muscle  inward  as  it  forms  the  roof  of  Hunter's  canal.  The  space  be- 
tAveen  the  vastiis  internus  and  the  adductor  magnus  is  dissected  and  the  in- 
ternal saphenous  nerve  is  found  in  the  roof  of  Hunter's  canal  and  retracted 
out  of  the  Avay. 

LIGATION  OF  THE  POPLITEAL  ARTERY 

The  popliteal  artery  is  a  continuation  of  the  femoral  and  extends  from 
the  opening  in  the  adductor  magnus  at  the  junction  of  the  middle  and  lower 
thirds  of  the  thigh  downward  and  outward  through  the  popliteal  space  to 
a  point  behind  the  knee  joint  and  then  directly  downward  to  the  lower 
border  of  the  popliteus  muscle,  where  it  divides  into  the  anterior  and  posterior 
tibial  arteries.  The  important  structures  in  front  of  the  popliteal  artery  are 
the  lower  surface  of  the  femur,  the  posterior  ligament  of  the  knee  joint,  the  up- 
per end  of  the  tibia,  and  the  popliteus  muscle.  Beliind,  or  superficially,  are 
the  inner  head  of  the  gastrocnemius  muscle,  the  aponeurotic  arch  of  the  soleus 
muscle  and  the  popliteal  vein,  which  lies  behind  the  artery  throughout  its 
course  but  crosses  obliquely  from  the  outer  to  the  inner  side.  The  vein  is  close 
to  the  arter^^  The  internal  popliteal  nerve  is  posterior  to  the  popliteal  vein, 
and  is  tirst  external  and  posterior,  then  crosses  the  popliteal  vein  and  artery 
and  assumes  a  posterior  and  internal  relation  at  the  end  of  the  popliteal  artery. 

The  artery  is  but  seldom  ligated,  though  it  may  be  tied  either  in  its  up- 
per or  lower  part.  It  may  be  approached  at  its  upper  portion  from  the  inner 
aspect  of  the  thigh  or  from  the  inner  part  of  the  popliteal  space  behind.  In  its 
lower  portion  it  is  exposed  from  the  lower  part  of  the  popliteal  space  behind. 
From  the  inner  side  of  the  thigh  an  incision  is  made  about  three  and  one-half 
inches  long,  beginning  opposite  the  junction  of  the  middle  and  lower  thirds  of 
the  thigh  and  running  parallel  with  and  immediately  behind  the  tendon  of  the 
adductor  magnus.  After  exposing  the  anterior  edge  of  the  sartorious,  which 
is  retracted  backward,  together  with  the  internal  saphenous  A-ein,  the  tendon 
of  the  adductor  magnus  is  identified  and  drawn  forAvard  and  the  artery  is 
sought  between  this  tendon  and  the  semimembranous,  Avhicli  is  retracted  back- 
ward.    The  popliteal  vein  lies  next  to  the  artery  and  behind.     The  popliteal 


116  OPERATIVE    SURGERY 

nerve  is  posterior  to  the  vein.  If  ligation  is  made  in  the  popliteal  space  it 
should  be  either  at  the  upper  or  lower  angle.  At  the  upper  angle,  an  incision 
is  made  about  three  and  one-half  inches  in  length  with  its  center  about  the 
upper  apex  of  the  popliteal  space  down  to  the  middle  of  this  space.  The  ham- 
string muscles  are  retracted  to  the  outer  and  inner  sides  respectively  and  the 
popliteal  nerve  and  vein  are  retracted  out.  In  the  lower  portion  of  the  poplit- 
eal space  the  incision  is  made  so  that  its  middle  is  about  opposite  the  lower 
portion  of  the  popliteal  space.    The  nerve  and  vein  there  are  retracted  inward. 

LIGATION  OF  THE  ANTERIOR  TIBIAL  ARTERY 

The  anterior  tibial  artery  is  seldom  ligated.  It  is  one  of  the  terminal 
branches  of  the  popliteal  artery  and  passes  forward  between  the  two  heads 
of  the  tibialis  posticus  muscle  and  appears  on  the  front  part  of  the  interos- 
seous membrane  between  the  tibia  and  fibula.  It  descends  on  the  front  part 
of  this  membrane,  then  on  the  tibia,  and  terminates  at  the  front  of  the  ankle 
joint  by  becoming  the  clorsalis  pedis  artery.  The  important  structures  in 
front  of  this  artery  are  the  anterior  tibial  nerve  about  its  middle,  the  tibialis 
anticus  and  the  extensor  longus  digitorum  above  and  the  extensor  proprius 
hallucis  below.  Externally  are  the  anterior  tibial  nerve  above  and  below,  the 
extensor  longus  digitorum  above,  the  extensor  proprius  hallucis.  Internally 
are  the  tibialis  anticus  above  and  the  extensor  proprius  hallucis  Avhich  crosses 
the  artery  below.  The  artery  lies  behind  a  line  from  the  inner  side  of  the  head 
of  the  fibula  to  a  point  midway  between  the  malleoli.  The  lower  third  is  the 
most  frequent  site  of  ligation  and  the  incision  for  this  ligation  should  be 
made  about  three  inches  in  length  in  the  lower  third  of  the  leg.  It  is  important 
to  identify  the  tendon  of  the  tibialis  anticus  and  the  tendon  of  the  extensor 
proprius  hallucis.  The  artery  will  be  found  between  these  two,  the  muscles 
and  tendons  lying  on  the  anterior  aspect  of  the  tibia  with  the  anterior  tibial 
nerve  on  the  outer  side.     It  is  accompanied  by  two  vente  comites. 

LIGATION  OF  THE  DORSALIS  PEDIS 

This  artery  is  a  continuation  of  the  anterior  tibial  artery  and  extends  from 
the  bend  of  the  ankle  on  the  tibial  side  of  the  foot  to  the  apex  of  the  first 
metatarsal  space.  The  important  relations  in  front  are  the  inner  tendons  of 
the  extensor  brevis  digitorum  at  the  beginning  of  the  artery,  to  the  outer  side 
are  the  tendons  of  the  extensor  longus  digitorum  and  the  anterior  tibial  nerve. 
To  the  inner  side  is  the  tendon  of  the  extensor  proprius  hallucis.  The  artery 
lies  behind  a  line  drawn  from  the  mid-point  of  a  line  connecting  the  two  malleoli 
to  the  proximal  end  of  the  first  metatarsal  space. 

An  incision  is  made  about  two  inches  long  in  the  line  of  the  artery  between 
the  tendons  of  the  extensor  proprius  hallucis  on  the  inner  side  and  the  extensor 
longus  digitorum  on  the  outer. 


LIGATION    OF    BLOOD   VESSELS  117 

LIGATION  OF  THE  POSTERIOR  TIBIAL  ARTERY 

This  artory  is  the  other  and  the  hir^'er  terminal  brancli  of  the  popliteal 
and  extends  from  the  loAver  border  of  the  popliteal  muscle  down  the  back 
of  the  leg  between  the  superficial  and  deep  muscles,  ending  at  a  point  midway 
between  the  tip  of  the  internal  malleolus  and  the  os  calcis.  In  front  are  the 
tibialis  posticus  and  ilexor  longus  digitorum.  Behind  are  the  superficial  mus- 
cles of  the  posterior  portion  of  the  leg,  the  gastrocnemius  and  the  soleus,  and 
the  deep  intermuscular  fascia.  The  posterior  tibial  nerve  lies  close  to  the  artery 
and  is  first  to  the  inner  side,  then  crosses  it  posteriorly  to  the  outer  side,  which 
is  its  relation  in  the  lower  two-thirds.  The  artery  lies  behind  a  line  drawn 
from  about  two  inches  below  the  center  of  the  popliteal  space  to  midway  between 
the  tip  of  the  internal  malleolus  and  the  apex  of  the  heel. 

To  ligate  the  posterior  tibial  in  its  lower  third,  which  is  the  usual  place, 
an  incision  about  two  inches  in  length  is  made  and  should  fall  midway  between 
the  inner  border  of  the  tendo  achillis  and  the  inner  border  of  the  tibia.  The 
posterior  tibial  nerve  lies  to  the  outer  side.  If  the  artery  is  to  be  ligated  at 
its  extremity  an  incision  is  made  about  one  inch  in  length  posterior  to  the  inner 
malleolus.  The  internal  saphenous  vein  should  be  retracted  or  divided  and  the 
annular  ligament  divided.  The  artery  is  found  between  the  tendons  of  the 
flexor  longus  digitorum  and  the  flexor  longus  hallucis,  the  nerve  being  to  the 
outer  or  fibular  side. 

Many  of  the  ligations  detailed  here  are  not  often  called  for  in  modern 
surgery.  Others,  as  in  ligation  of  the  tibial  arteries  in  the  upper  portions  and 
ligations  of  the  pudic  arteries,  are,  as  Binnie  says  "more  anatomical  exercises 
than  practical  operations  in  surgerj^"  They  can  be  worked  out  on  the  cadaver 
by  identifying  the  anatomical  structures. 


CHAPTER  IX 
ANEURISMS 

An  aneurism  is  a  cavity  that  communicates  with  circulating  arterial 
blood.  The  two  general  classifications  of  aneurisms  are  the  true  and  the  false. 
A  false  aneurism  is  formed  from  a  hematoma  and  is  equivalent  to  the  later 
stages  of  the  so-called  pulsating  hematoma.  If  in  an  injury  to  an  artery, 
blood  is  poured  out  and  a  hematoma  forms  sul^icient  to  prevent  further 
bleeding,  the  cavity  in  the  center  of  the  hematoma  and  communicating  with 
the  artery,  may  become  lined  Avith  endothelium  and  the  tissues  in  the 
neighborhood  form  a  connective  tissue  sac.  This  is  a  typical  false  aneu- 
rism. A  true  aneurism  is  not  a  tumor  in  the  ordinarily  accepted  meaning, 
for  a  tumor  is  new  tissue  that  has  sprung  from  a  matrix  of  cells.  A  true 
aneurism  is  a  dilatation  of  a  previously  existing  vessel  and  is  not  in  any  real 
sense  new  tissue,  but  merely  an  increase  of  previously  existing  tissue. 

Surgical  operations  for  aneurism  include  various  methods,  such  as  Aviring, 
electric  puncture,  direct  and  indirect  compression,  ligature,  incision,  ob- 
literation of  the  sac,  and  excision  of  the  sac  alone  or  combined  with  the 
substitution  of  a  segment  of  vein. 

We  will  first  consider  the  methods  particularly  applicable  to  aneurisms 
of  the  aorta  as  these  aneurisms  cannot  be  reached  by  the  direct  attacks  em- 
ployed elsewhere.  "Needling"  was  advised  by  McEwen  in  1890.  The  method 
is  quite  uncertain,  though  McEwen  reports  satisfactory  results.  It  consists 
of  the  introduction  into  the  sac  of  a  long,  fine  needle  which  scratches  thor- 
oughly all  of  the  lining  of  the  sac.  This  is  followed  by  the  deposition  of 
fibrin  and,  according  to  McEwen,  the  fibrin  thrown  down  after  needling  is 
peculiarly  firm.  The  operation,  however,  has  not  been  adopted  by  many 
surgeons. 

The  introduction  of  wire  into  an  aneurism  was  first  done  by  Moore,  of 
London,  in  1864.  It  has  been  widely  used,  particularly  in  connection  with  the 
modification  by  Corracli,  in  1879,  of  passing  a  galvanic  current  through  the 
wire.  Finney,  of  Baltimore,  has  had  very  favorable  experience  with  this 
method  and  reports  several  cases  much  benefited  and  some  apparentlj^  cured. 
Finney  recommends  the  wire  originally  proposed  by  Hunner,  which  consists  of 
a  silver  alloy  containing  seventy-five  parts  of  copper  to  1,000  parts  of  silver. 
This  wire  is  wound  tightly  on  a  wooden  spool,  in  order  to  make  it  coil,  and 
should  be  of  such  size  as  will  readily  pass  through  the  ordinary  aspirating 
needle.  The  needle  is  insulated  with  a  coat  of  the  best  French  lacquer  to 
within  a  short  distance  of  its  point.  This  prevents  an  electrolytic  burn  that 
might  be  the  site  of  a  subsequent  hemorrhage.     Under  local  anesthetic  the 

lis 


ANEURISMS  119 

iieeilk'  is  iiisei-tcil  into  llic  sldii  ^vlli(•ll  is  (li'awii  to  one  side  so  that  wiieu  the  needle 
is  removed  the  opening  in  the  skin  is  not  opposite  the  opening  in  the  sac. 
Finney  nses  ten  feet  oL'  wire,  claiming  that  a  larger  amount  may  prevent 
the  contraction  of  the  clot  in  the  sac.  The  needle  is  inserted  slowly  until 
arterial  blood  appears  in  spurts  through  the  needle.  The  end  of  the  wire 
should  be  engaged  in  the  lumen  of  the  needle  before  the  needle  is  inserted. 
At  first  a  small  amount  of  blood  will  spurt  around  the  wire.  The  Avire  is  then 
threaded  through  into  the  aneurism,  care  being  taken  that  no  portion  of  the 
needle  that  is  not  protected  with  lacquer  comes  in  contact  with  the  skin.  The 
positive  pole  of  a  galvanic  battery  is  then  connected  with  the  wire,  a  negative 
pole  being  placed  at  the  patient's  back.  This  is  important  as  the  negative 
pole  to  the  wire  will  cause  disorganization  of  the  clot  rather  than  hasten 
its  formation.  The  current,  according  to  Finney,  should  not  be  greater  than 
seventy-five  m.a.,  but  should  be  continued  at  least  an  hour.  In  abdominal 
aneurisms,  the  aneurism  should,  of  course,  be  fully  exposed  and  the  viscera 
packed  away.  This  is  done  under  local  anesthesia.  After  the  current  has 
been  passed  at  least  an  hour  in  thoracic  aneurisms  the  needle  is  slowly  re- 
moved, twisting  it  somewhat  in  order  to  withdraw  it  gradually.  The  skin 
is  depressed  around  the  wire  and  the  wire  cut  flush  with  the  skin.  The  skin 
is  then  pinched  up  and  the  end  of  the  wire  will  disappear  under  the  skin. 
If  the  skin  has  originally  been  drawn  to  one  side,  there  is  no  direct  com- 
munication between  the  hole  in  the  skin  and  that  in  the  sac. 

Aneurisms  of  the  aorta  should  first  be  carefully  studied  with  the  x-ray 
before  being  subjected  to  wiring.  A  diffuse  dilatation  or  a  spindle-shaped 
aneurism  obviously  cannot  be  treated  by  such  a  measure,  which  should  be 
reserved  for  the  distinctly  sacculated  type.  Attempts  have  been  made  to 
cure  aneurisms  of  the  abdominal  aorta  b}^  ligature,  and  the  abdominal  aorta 
has  so  far  been  ligated  for  various  causes,  chiefly  for  aneurism,  about  twenty 
times  with  fatal  result  in  each  case.  In  some  abdominal  aneurisms  the  metal 
band  introduced  by  Halsted  seems  indicated.  By  this  means  the  circulation 
through  the  aneurism  can  be  greatly  diminished  though  not  entirely  obliterated, 
and  after  collateral  circulation  has  been  sufficiently  established  the  band  may 
be  removed  and  a  ligature  applied.  If,  however,  important  arteries,  such  as 
the  renal  or  the  celiac  axis,  arise  from  a  prominent  portion  of  the  sac,  the 
case  would  seem  utterly  hopeless,  as  any  method  that  obliterates  the  sac 
would,  of  course,  occlude  these  arteries,  with  the  necessity  of  a  fatal  result. 

This  principle  of  the  gradual  obliteration  of  arteries  has  added  greatly 
to  the  eifectiveness  of  treatment  of  certain  types  of  aneurisms.  It  maj^  be 
sometimes  emploj^ed  as  a  direct  cure  but  its  chief  value  lies  in  the  development 
of  collateral  circulation  by  the  diminution  of  the  arterial  lumen  .without 
entirely  occluding  it.  This  was  first  worked  out  by  Halsted^  who  made  use 
of  aluminum  bands  with  smooth  edges.  These  bands  were  placed  around  the 
artery  and  curled  into  position  by  a  special  device.  Later  the  bands  were 
modified  bv  Matas,  -who  used  them  in  a  long  ribbon  in  the  form  of  an  aneu- 


ijour.  Exper.  Med.,   1901,  xi. 


120  OPERATIVE    SURGERY 

rism  needle.  The  bands  may  be  molded  and  placed  with  the  fingers.  They 
vary  in  width  from  y^c  to  Yi,-,  of  an  inch  and  are  about  as  thick  as  a  sheet  metal 
gauge  No.  23,  which  is  0.6  mm.  in  thickness. 

In  some  interesting  experimental  work  Halsted-  has  found  that  there  is 
freciuently  dilatation  of  the  vessel  on  the  distal  side  of  the  band  which  ap- 
pears to  be  difficult  to  explain,  but  which  he  thinks  is  due  to  a  form  of  eddy 
or  whirl  in  the  partially  obstructed  current. 

In  the  treatment  of  aneurisms  of  the  extremities  it  is  important  to  de- 
velop the  collateral  circulation  to  as  great  an  extent  as  possible,  before  any 
attempt  is  made  to  excise  the  aneurism  or  to  close  the  sac.  This  may  be  done 
by  hot  packs  around  the  limb  several  times  a  day,  extending  over  a  period 
of  a  half  to  one  hour  at  a  time.  Digital  pressure  on  the  artery  or  pressure 
by  a  special  apparatus  may  be  used.  The  circulation  should  be  tested,  as 
suggested  by  Matas,  by  applying  a  firm  Esmarch  bandage  from  the  extremity 
of  the  limb  to  the  trunk.  The  main  artery  is  then  compressed,  the  Esmarch 
removed,  and  note  made  of  the  returning  circulation  which  is  carried  on 
collaterally.  In  the  thigh  a  hyperemic  flush  extends  quickly  to  the  knee,  but 
may  go  much  more  slowly  or  not  at  all  to  the  foot.  If  the  flush  does  not 
reach  the  ankle,  operation  should  be  postponed  and  treatment  with  hot  packs 
or  local  compressions  of  the  artery  is  instituted  until  collateral  circulation 
has  been  satisfactorily  established.  The  most  serious  objection  to  this  method 
of  testing  is  that  it  is  inapplicable  in  negroes  or  people  with  a  very  dark 
skin. 

Compression  is  recognized  as  one  of  the  oldest  methods  of  treating  aneu- 
risms. While  various  appliances  have  been  used  they  have  not  been  Cjuite 
so  satisfactory  as  digital  compression  properly  applied.  It  requires  a  number 
of  as.sistants  who  can  relieve  each  other  from  time  to  time.  The  skin  where 
pressure  is  to  be  made  is  covered  with  French  chalk.  Each  assistant  is  in- 
structed as  to  the  amount  of  pressure  necessary,  the  direction  in  which  it  must 
be  made,  and  the  manner  of  changing  from  one  assistant  to  another,  so  at  no 
time  during  the  treatment  is  the  artery  without  compression  at  or  about  the 
same  point.  The  femoral  artery  below  Poupart's  ligament  is  the  most  favor- 
able location  for  digital  compression.  Each  sitting  lasts' four  hours.  Some- 
times one  sitting  will  result  in  a  cure,  but  usually  ten  or  even  twenty  sittings 
are  necessary.  This  method  is  unsatisfactory  and  uncertain  in  comparison 
with  modern  methods  and  is  by  no  means  free  from  danger  of  gangrene. 

The  elastic  compression  of  Keid  consists  of  bandaging  the  limb  by  an 
elastic  bandage  up  to  the  aneurism  and  then  skipping  the  aneurism,  but 
bandaging  the  limb  above  it.  In  this  way  the  blood  is  shut  off  above  and 
below  the  aneurism  and  clotting  is  often  produced.  The  bandage,  however, 
should  not  be  left  on  longer  than  an  hour  and  a  half  and  in  elderly  people 
half  this  time  is  much  safer.  According  to  Delbet,  this  treatment  leads  to 
gangrene  twice  as  often  as  digital  compression. 

Extreme  flexion  has  been  suggested  bv  a  number  of  surgeons,  but  is  often 


=Surg.,  Gynec.  &  Obst.,  Dec,  1918,  pp.  547-554. 


ANEURISMS 


121 


called  the  method  of  Hart.  It  is  applicable  in  the  treatment  of  aneurisms 
developing  in  the  popliteal  region,  in  the  groin  or  in  the  elbow.  It  consists 
of  forced  flexion  whicli  must  be  maintained  about  fourteen  days.  It  is  ex- 
ceedingly painful  and  cures  only  about  one-third  of  the  cases. 

The  classical  methods  of  using  the  ligature  for  the  cure  of  aneurism  have 
been  long  established.  The  operation  of  Antyllus  has  been  practiced  since 
the  second  century  of  the  Christian  era,  and  has  on  the  whole  given  exceed- 
ino'ly  satisfactory  results.  It  consists  of  ligating  the  artery  close  to  the  aneu- 
rism, both  centrally  and  distally,  and  then  incising  the  sac   (Fig.  59).     In 


Fig.   59. — The  ODeration  of  Antyllus   for   aneurism.        Fig.   62. — The  operation  of  Brasdor. 
Fig.   60. — The  operation  of  Anel  for  aneurism.  .    Fig.   63. — The  operation  of   \A  ardrop. 

Fig.   61.— The  operation  of  John    Hunter.  Fig.  64.— The  operation  of  Pasqum. 

Fig.   65. — The  operation  of  Purmann. 

preantiseptic  days  the  suppuration  following  this  method  made  the  mortality 
high,  but  in  spite  of  that  the  percentage  of  cures  has  been  gratifying. 

Anel's  method,  first  used  in  1710,  consists  in  ligating  the  artery  centrally  but 
as  close  as  possible  to  the  sac  (Fig.  60).  In  preantiseptic  days  where  suppura- 
tion was  a  rule,  secondary  hemorrhage  was  frequent.  It  was  thought  this 
was  partly  due  to  the  fact  that  the  artery  near  the  sac  was  very  likely  to  be 
diseased;  so  John  Hunter  established  a  new  principle  of  ligating,  in  1785,  by 
applying  the  ligature  centrally,  but  at  some  distance  from  the  aneurism  (Fig. 
61).  In  this  method  branches  are  given  off  from  the  main  artery  between 
the  ligature  and  the  aneurism.     It  is  still  used  to  some  extent  but  has  many 


122  OPERATIVE    SURGERY 

disadvantages.  First  of  all,  it  assumes  that  the  artery  is  less  diseased  at  a 
distance  from  the  aneurism  than  close  to  it.  This  is  by  no  means  always 
true.  Secondly,  the  liability  tf)  gangrene  is  increased,  because  if  the  sac  is 
occluded  by  a  clot  there  "will  be  two  o])structions  to  the  current  instead  of  one, 
the  obstruction  at  the  site  of  ligature  and  another  further  down  where 
the  aneurism  is  closed  by  clots.  Thus  the  collateral  circulation  between  the 
ligature  and  the  sac  is  greatly  diminished  and  the  l)lood  has  to  pass  through 
two  sets  of  collateral  branches,  one  from  above  the  ligature  to  vessels  be- 
tween the  ligature  and  the  aneurism,  and  one  from  this  set  to  the  vessel  be- 
low the  aneurism,  in  order  to  maintain  the  nutrition  of  the  limb.  If,  how- 
ever, the  collateral  circulation  is  free,  the  aneurism  may  not  be  sufficiently 
occluded  by  clots  and  no  cure  will  result.  AVith  modern  technic  and  an  ab- 
sorbable ligature  the  operation  of  Anel  is  far  superior  to  that  of  Hunter. 

Brasdor  instituted  the  method  of  distal  ligation  in  1798,  ligating  distally 
the  main  trunk  (Fig.  62).  Wardrop,  in  1825,  applied  ligatures  distally  to  one 
or  two  of  the  main  branches  of  the  artery  (Fig.  63).  This  was  used  in  aneu- 
rism of  the  innominate  Avhere  the  carotid  artery  was  often  tied.  The  applica- 
tion of  a  ligature  immediately  above  and  below  without  opening  the  sac 
is  called  Pasquin's  method  and  was  first  applied  in  1812  (Fig.  64). 

Ligation  on  each  end  and  close  to  the  aneurism  with  extirpation  of  the  sac 
has  been  known  as  the  operation  of  Purmann,  who  used  it  in  1680  (Fig.  65). 
It  is  necessary  to  have  complete  hemostasis  either  by  the  tourniquet,  or  by 
clamping,  or  by  temporary  ligatures.  Often  large  collateral  vessels  open  into 
the  sac,  so  a  central  ligature  may  not  completely  control  the  hemorrhage. 
It  is  also  important  to  preserve  the  vein  in  extirpating  the  sac,  for  if  the  A'ein 
is  injured  or  ligated,  gangrene  is  more  likely  to  occur.  Bleeding  is  con- 
trolled by  sutures  which  do  not  go  deeper  than  necessary,  as  packing,  if  de- 
pended upon  to  stop  bleeding  may  also  interfere  Avith  the  collateral  circula- 
tion. 

Ligation  with  extirpation  of  the  sac  compares  very  favorably  in  results 
with  simple  ligature,  as  it  has  a  somewhat  loAver  mortality  in  a  large  number 
of  cases  than  the  Hunterian  method  of  ligation,  and  the  dangers  of  gan- 
grene are  about  the  same. 

The  greatest  improvement  in  the  treatment  of  aneurisms  in  modern  times 
is  the  operation  of  IMatas,  which  Avas  first  performed  by  him  in  1888,  on  a 
brachial  aneurism  that  had  not  been  cured  by  either  proximal  or  distal 
ligature.  The  operation  is  subdivided  into  three  diiferent  types,  though  the 
principle  is  the  same  in  each.  The  fact  that  extirpation  of  the  sac,  and 
the  Syme  operation  in  which  the  artery  is  ligated  within  the  sac,  are  followed 
by  a  comparatively  low  mortality  and  a  high  rate  of  cure  makes  it  evident 
that  the  nearer  the  ligature  is  placed  toward  the  sac,  other  things  being 
equal,  the  better  the  results  will  be.  The  objections  to  extirpation  are  ob- 
vious. The  operation  is  not  only  difficult,  involving  the  enucleation  of 
consideraljle  tissue,  but  there  is  a  likelihood  of  injury  to  the  veins  or  nerves, 


ANEURISMS 


123 


and,  most  important  ol"  all,  llic  tissues  emu'leated  often  carry  collateral  ves- 
sels that  are  highly  important. 

The  three  types  of  the  operation  of  Matas  arc  obliterative  endo-aneurismor- 
rhaphy,  restorative  endo-aneurismorrhaphy,  and  reconstructive  endo-aneuris- 
morrhaphy  (Figs.  G6,  67  and  68).  The  obliterative  type  may  be  used  in  any 
form  of  aneurism,  but  it  was  particularly  designed  for  cases  in  which  there 
are  two  openings  in  the  sac  some  distance  apart,  or  when  the  sac  is  peculiarly 
friable.  Hemostasis  is  ol)tained  by  a  tourniquet  if  possible,  or  if  this  is  imprac- 
ticable by  the  clamps  devised  by  Crile  or  Matas,  or  by  the  clamps  that  I 
devised  for  lateral  suture  of  blood  vessels  (p.  136).  These  clamps  are  placed 
on  the  artery  and  its  main  branches  both  above  and  below  the  sac.  The  sac 
should  not  be  dissected  out,  so  whenever  a  tourniquet  can  be  used  instead 


Fig.    66. — Obliterative   endo-aneurismorrhaphy    of    Matas. 

of  a  clamp  it  is  always  preferred.  By  bearing  in  mind  the  principle  on  which 
the  operation  is  founded — conserving  every  possible  collateral  branch  m 
the  sac  and  surrounding  tissues— the  operation  can  be  carried  out  more  in- 
telligently. After  the  tourniquet  has  been  applied  an  ample  incision  is  made 
through  the  skin  over  the  aneurism.  If  it  is  impossible  to  place  the  tourniquet, 
the  vessel  is  exposed  centrally  and  peripherally  a  few  inches  from  the  aneurism 
and  clamps  applied,  as  mentioned  above.  The  sac  is  then  opened  without  separat- 
ing it  from  the  surrounding  tissue  and  clots  are  thoroughly  removed.  A  suture 
of  chromic  or  tanned  catgut  in  a  small,  round,  curved  needle  is  passed  around 
the  openings  of  the  artery  taking  care  to  tie  the  openings  snugly  but  not 
using  too  much  force  as  the  suture  may  cut  out.  The  sac  is  searched  for 
other  openings  of  collateral  arteries  or  branches  and  these  are  also  closed. 
The  tourniquet  or  clamp  is  released  to  see  if  the  bleeding  in  the  sac  is  con- 
trolled and  is  immediately  reapplied.     Then  the  sac  is  obliterated  by  rows 


124 


OPERATIVE    SURGERY 


of  sutures  of  chromic  or  tanned  catgut,  the  first  row  running  preferably 
from  one  arterial  opening  to  another.  After  this  has  been  finished  another 
row  is  placed.  In  intraperitoneal  aneurisms  the  peritoneum  is  sutured  so  as 
to  cover  the  raw  surface.  The  manner  of  treating  the  sac  after  the  two  tiers 
of  obliterative  sutures  have  been  placed,  depends  largely  upon  the  condition 
of  the  sac  and  must  of  necessity  be  left  to  the  judgment  of  the  surgeon,  as 
in  plastic  work.  The  essential  features  are  to  close  the  arterial  openings 
into  the  sac  and  to  place  at  least  two  rows  of  continuous  chromic  or  tanned 
catgut,  obliterating  the  sac  as  far  as  possible  from  one  of  the  main  arterial 
openings  to  the  other.  After  this,  the  recesses  of  the  sac  are  folded  upon 
themselves  if  possible,  or  sutures  are  carried  through  a  double  thickness  of 
the  sac  and  tied  in  the  margin  of  the  wound,  or  else  brought  out  through 
the  skin.    All  dead  spaces  should  be  obliterated  and  the  wound  closed  without 


Fig.  i>l . — Restorative  endo-aneurismorrhaphy  of 
Matas. 


Fig.    68. — Reconstructive    endo-aneurismor- 
rhaphy of  Matas. 


drainage.  The  blood  current  is  gradually  turned  on  before  the  skin  is  sutured 
and  the  infolded  sac  is  pressed  upon.  Usually  there  is  but  little,  if  any  oozing, 
though  if  it  is  marked  the  tourniquet  should  be  reapplied  and  the  leak  stopped 
by  additional  sutures.  The  smooth  membrane  lining  the  inside  of  the  sac 
is  vascular  endothelium  and  requires  no  freshening  or  injury  to  heal,  but 
merely  snug  approximation  just  as  the  peritoneum  requires. 

Restorative  endo-aneurismorrhaphy  (Fig.  67)  is  applicable  Avhen  the  sac 
is  tough  and  resistant .  and  when  there  is  only  one  opening.  In  other  words, 
when  the  aneurism  springs  from  one  side  of  the  artery  and  the  whole  of  the 
artery's  circumference  is  not  involved.  This  does  not  occur  very  frequently. 
In  such  cases  the  opening  is  sutured  either  by  surrounding  it  with  a  purse- 
string  suture  or  by  whipping  it  over  with  a  continuous  stitch.  The  rest  of 
the  procedure  is  identical  with  the  obliterative  method. 


ANEURISMS  125 

Reconstructive  eiido-aiieurisiuorrliapliy  (Fig.  68)  is  recommcJided  by  Matas 
in  cases  in  wliicli  the  two  openings  are  close  together,  where  there  is  but  little  athe- 
roma, and  where  the  sac  is  tough  and  holds  the  sutures  well.  The  sac  is  cleaned  of 
clots  and  washed  out  with  salt  solution.  Matas  recommends  that  a  soft  rubber 
catheter,  well  anointed  Avith  vaseline  and  which  fits  snugly  into  the  arterial 
opening,  be  inserted  and  interrupted  sutures  of  chromic  catgut  be  placed  at 
close  intervals  over  the  catheter.  After  the  sutures  have  been  placed  the 
catheter  is  withdrawal  and  the  sutures  are  tied  snugly.  The  rest  of  the  sac  is 
obliterated  as  in  the  other  methods. 

In  all  of  these  methods  care  should  be  taken  not  to  take  a  deeper  bite  with 
the  suture  than  is  necessary  to  secure  a  firm  hold.  The  needle  may  wound  the 
accompanying  vein  or  nerve,  or  if  inserted  too  deeply,  may  occlude  some 
collateral  vessel. 

Reconstructive  endo-aneurismorrhaphy  probably  sooner  or  later  either  be- 
comes obliterative  or  fails  to  cure.  The  fact  that,  in  several  instances,  thrombi 
which  formed  after  the  reconstructive  operation  were  later  dislodged  and  acted 
as  emboli,  is  also  a  serious  objection  to  this  method.  In  the  light  of  modern 
blood  vessel  suturing,  we  can  hardly  expect  the  reconstructed  artery  to  remain 
patent.  In  experimental  work  under  the  best  conditions  with  comparatively 
healthy  blood  vessels  and  using  the  finest  sutures  of  silk  and  the  finest  needles, 
it  is  impossible  to  avoid  occlusion  of  the  artery  in  a  considerable  number  of 
cases  even  after  some  experience  in  this  work.  We  can  hardly  expect,  then, 
that  suturing  with  comparatively  coarse  needles  and  catgut  in  diseased  tissue 
will  produce  a  permanently  patent  artery.  If  there  is  merely  a  small  open- 
ing the  restorative  method  may  be  indicated,  but  the  eventual  result  will 
probably  be  better  if  the  obliterative  method  is  always  used  instead  of  the 
reconstructive  type.  The  only  advantage  in  the  reconstructive  operation  is 
that  for  a  short  time  blood  flows  through  its  natural  channel  and  the  con- 
sequent strain  upon  collateral  circulation  will  not  be  so  great.  This  advan- 
tage, however,  seems  offset  by  the  dangers  of  sudden  emboli  from  the 
breaking  loose  of  a  thrombus,  by  the  fact  that  sooner  or  later  the  channel 
in  all  probability  becomes  obliterated,  and  by  the  further  fact  that  recurrences  are 
much  more  common  after  the  reconstructive  than  after  the  obliterative  method. 
Matas  has  collected  statistics  which  prove  beyond  doubt  that  wherever  endo- 
aneurismorrhaphy  can  be  applied  it  is  far  more  satisfactory  than  either  liga- 
ture or  extirpation;  not  only  is  the  mortality  rate  less  but  gangrene  is  exceed- 
ingly rare. 

Extirpation  of  aneurisms  has  been  done  with  direct  suture  of  the  ar- 
tery by  the  end-to-end  method.  This  is  only  applicable  Avhere  the  site  of 
the  aneurism  involves  a  very  short  section  of  the  artery  and  Avhere  the 
ends  of  the  artery  are  comparatively  healthy.  It  has  been  done  by  Lexer, 
Stich,  and  Enderlen  in  popliteal  aneurisms.  The  limb  is  flexed  and  kept  in 
this  position  for  several  weeks  by  plaster  of  Paris.  After  the  sixth  week  the 
knee  may  be  gradually  extended.  This  method  has,  of  course,  a  very  limited 
application. 


126  OPERATIVE    PT'RGERY 

The  ideal  treatment  of  aiieiu'isni  is  to  excise  the  sac  and  at  tlie  same  time 
to  restore  the  arterial  channel.  This  may  l)e  accomplished  by  substituting 
a  segment  of  vein.  The  A'cin  that  accompanies  tlie  artery  has  been  used,  though 
it  -would  1)0  much  better  to  utilize  some  other  vein.  Obviously,  when  the  direct 
circulation  is  deficient  on  account  of  the  aneurism,  and  collateral  circulation 
is  poor,  closing  the  main  artery  by  ligature  or  obliteration  of  the  sac — even 
by  the  method  of  Matas — is  fraught  with  great  danger  and  the  indications  are, 
if  possible,  to  reestablish  the  circulation  by  the  ideal  method.  In  a  diseased 
arterj^,  arterial  sutures  would  not  seem  to  be  satisfactory,  and  it  is  certainly 
more  desirable  to  suture  healthy  arteries  as  in  traumatic  aneurisms  than 
the  diseased  vessels  of  spontaneous  aneurisms.  However,  the  brilliant  case  of 
Lexer,  already  referred  to  (p.  75),  in  which  he  excised  an  aneurism  in- 
volving a  portion  of  the  external  iliac  and  femoral  arteries  and  sutured  into 
the  defect  a  segment  of  the  saphenous  vein  with  perfect  success,  shows  the 
great  possibilities  of  this  operation.  Bernheim,  of  Baltimore,  has  successfully 
excised  a  popliteal  aneurism  and  sutured  in  a  segment  of  vein. 

If  success  is  to  be  attained  in  suturing  diseased  arteries  the  best  possible 
technic  should  be  used.  As  already  pointed  out,  it  is  not  likely  that  recon- 
structive endo-aneurismorrhaphy,  in  which  comparatively  coarse  needles  and 
catgut  are  used,  will  result  in  a  perinanently  open  channel.  Certainly  in  ex- 
perimental work  such  technic  Avould  invariably  be  followed  by  thrombosis  in 
healthy  arteries,  and  in  diseased  arteries  we  have  no  right  to  expect  better 
results.  It  is  practically  impossible,  however,  to  use  the  technic  of  arterial 
suturing  in  the  bottom  of  a  sac  where  the  tension  on  the  stitches  must  be 
considerable,  but  after  the  sac  is  excised  a  segment  of  vein  can  be  sutured 
to  the  ends  of  the  artery  with  the  regular  technic  for  end-to-end  suture.  While 
there  is  some  danger  of  the  segment  becoming  occluded  by  thrombus,  it  seems 
for  the  reasons  mentioned  that  if  it  is  necessary  to  reestablish  the  current  of 
the  blood,  it  should  be  done  not  by  the  reconstructive  method  of  Matas,  but 
by  excision  of  the  sac  and  suturing  into  the  defect  a  segment  of  vein.  Ee- 
versing  the  circulation  and  then  excising  the  aneurism  has  been  tried.  This 
has  none  of  the  advantages  of  transplantation  of  a  venous  segment. 

OPERATION  ON  ANEURISM  OF  SPECIAL  ARTERIES 

Aneurisms  of  the  thoracic  aorta  are  by  far  the  most  freciuent  aneurisms, 
which  would  naturally  be  expected  from  the  strain  to  which  this  great  ves- 
sel is  subject.  The  proper  treatment  is  medical  treatment  though  in  saccu- 
lated thoracic  aneurisms  the  Moore-Corradi  method  may  be  used.  The 
technic  employed  by  Finney  is  probably  the  most  satisfactory  (pp.  118,  119).  A 
thorough  examination  by  x-ray  should  be  made  before  this  operation  is  at- 
tempted. The  average  course  of  a  thoracic  aneurism  is  a  little  more  than  a 
year.  There  has  been  one  ei¥ort  to  cure  a  thoracic  aneurism  by  ligating  the 
aorta.  This  was  done  by  Guinard,  of  Paris,  in  1904,  the  chest  being  opened 
posteriorly  by  an  osteoplastic  flap  and  a  ligature  placed  on  the  thoracic  aorta 


ANEURISMS  *  127 

just  l)elu^\•  llie  (MkI  of  llic  ;ircli.  When  llic  lit;';itiire  was  1  i^litciied,  pulsation 
in  tlie  femoral  artery  stoppi'd  and  the  lower  i)art  of  tlie  ])ody  became  pale  and 
cold,  but  in  a  few  minutes  the  eireulation  was  rcestal)lished  throug-h  the  in- 
tercostal and  other  vessels.  However,  the  blood  pressure  throug-h  the  collat- 
eral circulation  was  not  sufficient  for  the  renal  arteries  and  the  patient  died. 

Aneurisms  of  the  abdominal  aorta  are  scarcely  amenable  to  other  direct 
treatment  than  the  Moore-Corradi  method.  If  the  aneurism  is  above  the  renal 
arteries  or  involves  the  mesenteric,  its  obliteration  will  necessarily  result  fa- 
tally on  account  of  interference  with  the  function  of  the  kidney's  or  from  gan- 
grene of  the  intestines.  BeloAV  the  inferior  mesenteric  artery,  the  outlook 
seems  more  hopeful,  but  the  results  are  practically  equally  as  disastrous.  Of 
about  twenty  cases  of  ligature  of  the  abdominal  aorta  none  has  been  success- 
ful. The  strain  thrown  upon  the  heart  by  the  increased  blood  pressure  after 
such  a  ligature  is  enormous  and  this  high  pressure  and  a  competent  heart  are 
essential  to  the  proper  establishment  of  collateral  circulation.  Most  of  these 
jiatients  have  hearts  that  are  far  from  competent,  and  even  in  healthy  animals 
ligation  of  the  abdominal  aorta  usually  results  in  a  cardiac  death.  Even  if 
the  heart  should  survive  the  strain,  which  it  does  not  do  in  the  vast  majority 
of  cases,  there  is  still  the  risk  of  hemorrhage  and  the  possibility  of  sepsis  and 
shock.  The  iliac  arteries  have  been  ligated  for  abdominal  aneurisms,  follow- 
ing the  principle  of  Brasdor  and  AYardrop,  but  this  too  has  proved  fatal. 
Various  methods  of  compression  have  been  advocated  and  even  endo-aneuris- 
morrhaphy  has  been  tried,  but  unsuccessfully.  The  aluminnm  band  of  Hal- 
sted  or  of  Matas  which  would  produce  a  partial  but  not  a  complete  occlusion  of 
the  aorta  seems  to  offer  the  most  satisfactory  method  of  treatment,  if  wiring  and 
galvanism  are  not  indicated.  If  this  did  not  cure  the  anenrism  after  a  few  weeks, 
the  collateral  circulation  it  encouraged  might  justify  ligation  of  the  aorta. 
Various  problems,  particularly  the  strain  npon  the  heart,  render  treatment  of 
aneurisms  of  the  aorta  a  very  unsatisfactory  procedure.  Experimentally,  a 
portion  of  the  abdominal  aorta  has  been  resected  and  a  tube  sutured  into 
the  defect  (p.  90). 

Aneurisms  of  the  innominate  seem  to  offer  a  field  for  the  Moore-Corradi 
method,  though  they  have  been  treated  successfully  by  ligatures.  Apparently 
the  best  operation  is  distal  ligation  after  Wardrop  or  Brasdor.  Ligation  of 
the  right  common  carotid  and  the  right  subclavian  is  done  during  the  same 
operation,  tying  the  carotid  first  to  avoid  the  possibility  of  a  cerebral  embolus. 

Aneurisms  of  the  external  carotid  are  ciuite  rare,  but  occasionally  occur. 
Treatment  by  ligatures,  placing  the  ligatures  as  far  as  possible  from  the  bi- 
furcation of  the  common  carotid,  may  be  employed.  The  injection  into  the 
external  carotid  of  boiling  water  after  the  suggestion  of  AVyeth  might  be 
indicated,  as  the  collateral  circulation  with  the  carotid  of  the  other  side  is  so 
free  as  to  render  simple  proximal  ligation  much  less  likely  to  cure  here  than 
in  most  other  arteries.  Aneurisms  of  the  common  carotid  or  of  the  internal 
carotid  are  of  grave  significance  because  of  the  disastrous  effect  on  the  brain 
that  often  follows  when  these  arteries  are  tied.     The  danger  of  ligation  of  the 


128  ""      OPERATIVE    SURGERY 

common  carotid  increases  enormously  after  forty  years  of  age  and  is  due  to 
the  danger  of  a  diminished  blood  supply  to  the  brain.  In  the  young  with 
elastic  arteries  ligation  of  the  common  carotid  is  comparatively  free  from 
danger,  but  after  forty  years  of  age,  and  particularly  in  the  presence  of 
arteriosclerosis,  the  occurrence  of  cerebral  symptoms,  from  the  inability  of 
other  arteries  to  dilate  sufficiently,  is  frequent.  The  operative  measures  that 
have  been  used  are  the  classical  methods  of  ligation,  though  of  these  extirpa- 
tion with  the  double  ligature  has  proved  most  successful.  Proximal  ligature 
is  particularly  liable  to  cause  thrombi  in  the  sac  with  the  possibility  of  a 
piece  of  thrombus  becoming  loose  and  causing  an  embolus  in  the  brain.  This, 
of  course,  is  in  addition  to  the  danger  of  cerebral  symptoms  from  the  mere 
occlusion  of  the  artery.  Distal  ligation  or  extirpation  to  a  large  extent  avoids 
the  danger  of  embolus. 

It  has  been  found  that  when  cerebral  symptoms  occur,  serious  danger 
may  often  ])e  avoided  if  the  channel  of  the  artery  can  be  re-established  within 
a  few  hours  after  occlusion.  The  problem  in  connection  with  the  carotid 
artery  is  different  from  that  in  other  parts  of  the  body,  not  only  because  of 
the  immediate  danger  to  life  by  impairing  the  blood  supply  to  the  brain,  but 
because  we  have  a  method  of  determining  from  the  patient's  sensations  and 
symptoms  whether  occlusion  of  the  artery  is  safe.  Before  applying  a  liga- 
ture to  the  carotid,  except  in  cases  of  grave  necessity,  the  common  carotid 
should  be  exposed  under  local  anesthesia  and  gradually  occluded,  prefera- 
bly by  a  rubber  covered  Crile  clamp.  If  this  is  followed  by  cerebral  symp- 
toms of  a  psychic  nature,  by  paralysis  or  convulsions,  the  artery  should 
be  opened  at  once.  If  no  immediate  symptoms  occur,  the  clamp  may  be  left 
on  for  forty-eight  hours  and  then  a  ligature  applied  to  occlude  the  artery 
with  comparative  safety.  However,  cerebral  symptoms  sometimes  appear 
after  several  days,  though  they  are  usually  manifest  within  twenty-four  hours 
after  occlusion  of  the  artery.  If  complete  closure  is  not  possible  the  metal 
band  of  Halsted  may  be  rolled  around  the  artery  in  such  a  manner  as  par- 
tially to  occlude  it.  If  this  is  sufficient  to  cure  the  aneurism  no  further  treat- 
ment is  necessary:  but  if  not,  the  band  may  be  left  in  place  for  one  or  two 
weeks  until  the  other  arteries  have  taken  up  the  circulation,  and  then  a  liga- 
ture can  be  applied.  If  even  a  partial  occlusion  is  not  borne  the  outlook  is 
almost  hopeless,  though  the  possibility  of  excision  and  the  substitution  of  a 
segment  of  vein  should  be  considered. 

Subclavian  aneurisms  have  been  subjected  to  numerous  methods  of  treat- 
ment including  the  intrasaccular  ligation  of  Syme.  They  have  been  treated 
by  ligature,  both  distal  and  proximal,  and  the  innominate  artery  has  also  been 
ligated  in  efforts  to  cure.  The  results  have  usually  been  unsuccessful,  the 
mortality  being  large,  though  since  1890,  the  mortality  has  fallen  from  about 
eighty  per  cent  in  preantiseptic  days  to  twenty-two  per  cent.  The  metal  band 
may  also  be  used  here.  Excision  of  the  sac  seems  to  have  been  followed  by 
quite    satisfactory   results    as    compared    with    other    methods    of    treatment. 


ANEURISMS  V2!) 

Endo-aiieurisiiioi'i'li;ipliy  li;is  1)0(mi  altcni])t('(l,  tliou^ii  in  not  a  great  luimber 
of  cases,  and  the  results  usually  have  been  satisfactory. 

Axillary  aneurisms  may  be  treated  by  ligature,  by  band,  or  by  the  opera- 
tion of  IMatas.  In  certain  cases  where  the  circulation  can  be  controlled,  ex- 
cision of  the  aiKMirism  Avilh  tlie  substitution  of  a  piece  of  vein  may  be  con- 
sidered. This  has  been  done  by  Lexer  and  while  the  patient  died  from  gan- 
grene of  the  limb  it  Avas  found  that  the  occlusion  from  thrombus  occurred 
where  the  clamp  was  placed,  the  transplanted  section  of  vein  being  patent  and 
in  good  condition. 

The  treatment  of  aneurism  of  the  iliac  arteries  is  subject  to  somewhat 
the  same  objections  as  the  treatment  of  aneurism  of  the  aorta,  for  ligation  of 
these  large  arteries  produces  great  strain  upon  the  heart.  The  intrasaccular 
method  of  Matas  offers  in  certain  cases  excellent  results,  though  hemostasis 
may  be  difficult  or  impossible  except  by  compression  of  the  aorta. 

The  aluminum  metal  band  is  particularly  applicable  in  aneurisms  of  the 
iliac  arteries.  By  this  means  the  current  can  be  reduced  to  a  minimum  with- 
out being  obliterated  and  the  danger  of  gangrene  of  the  extremity  is  greatly 
lessened.  At  a  second  operation  after  a  few  weeks  the  artery  can  be  perma- 
nently occluded  near  the  site  of  the  band  by  ligatures.  This  principle  is  appli- 
cable to  aneurisms  anywhere  when  there  is  a  reasonable  doubt  that  the  collat- 
eral circulation  will  not  be  sufficient  if  the  artery  is  entirely  occluded  by  a 
ligature  or  if  the  endo-aneurismorrhaphy  of  Matas  is  contraindicated. 

The  common  and  external  iliac  arteries  may  be  regarded  as  practically 
an  extension  of  the  aorta.  Aneurisms  affecting  all  of  the  iliac  arteries  are 
lined  in  front  with  peritoneum.  They  tend  to  dilate  quickly  as  there  is  but 
little  resistance  in  front  and  they  rupture  easily  for  the  same  reason.  When 
rupture  occurs  it  is  usually  immediately  fatal,  though  occasionally  the  blood 
may  form  a  large  hematoma  under  the  peritoneum.  The  treatment  of  aneurisms 
of  the  iliac  arteries  may  be  some  form  of  ligature,  a  partial  constriction  by 
the  aluminum  band,  or  endo-aneurismorrhaphy.  Digital  compression  is  not 
practical,  though  it  may  be  tried  by  opening  the  abdomen  and  compressing 
the  common  iliac  or  the  aorta.  In  extirpation  or  in  endo-aneurismorrhaphy, 
temporary  hemostasis  can  be  effected  by  digital  pressure  on  the  abdominal 
aorta,  or  else  upon  the  trunk  of  the  common  iliac  near  the  bifurcation.  Even 
pressure  upon  the  aorta  may  not  give  an  entirely  dry  field  as  some  blood 
comes  through  the  distal  end  of  the  deep  epigastric  artery.  Pressure  upon 
the  iliac  is  often  unsatisfactory  because  of  the  free  anastomosis  with  the  inter- 
nal iliac  of  the  other  side.  Aneurisms  of  the  external  iliac  have  occasionally 
been  treated  by  digital  compression.  Compression  of  the  abdominal  aorta 
through  the  abdominal  w^all  is  possible  in  thin  patients,  but  is  best  done  within 
the  abdomen.  In  a  thin  patient  the  method  of  Momburg,  constricting  the 
abdomen  with  a  rubber  tube,  has  been  tried.  This  will  give  a  dry  field, 
but  there  is  always  danger  from  an  abdominal  tourniquet,  such  as  injury 
to  the  intestines,  though  the  originator  of  this  method  claims  otherwise. 
The  treatment  of  aneurism  of  the  iliacs  has  been  largely  by  the  ligature. 


130  OPERATIVE    SURGERY 

Double  ligation,  distal  and  proximal,  Avitli  extirpation  has  given  satisfac- 
tory results.  The  iliaes  should  be  ligatod  intraperitoneally.  Tlie  older  method 
of  stripping  up  the  peritoneum  and  nialdng  an  extensive  raw  surface  is 
unnecessary.  The  patient  may  ])e  ]nit  in  the  Trendelenburg  position  with 
the  intestines  packed  o&,  and  ligation  of  either  the  common  iliac  or  its  two 
branches  can  be  readil}-  done.  Endo-aneurismorrhaphy  has  been  tried  in  a 
few  cases  with  satisfactory  results.  Ligation  of  the  common  iliac  carries  a 
heavy  mortality  rate.  Matas  says  that  in  modern  times,  since  1880,  the  death 
rate  is  nearly  fifty  per  cent.  This  high  mortality  rate,  as  explained  by  Hal- 
sted  in  an  article  on  aneurisms  of  the  iliac,  is  largely  due  to  complications 
and  would  probably  noAV  be  considerably  lower.  The  fact,  however,  that  the 
mortality  from  simple  ligation  is  much  higher  than  from  extirpation  or  endo- 
aneurismorrhaphy  should  cause  the  later  method  to  be  employed  wherever 
possible. 

Aneurisms  of  the  Upper  femoral  artery  require  a  similar  hemostasis  to 
aneurisms  of  the  iliac,  as  it  is  impractical  to  place  a  tourniquet  at  this  level. 
The  external  iliac  gives  off  but  few  branches  whereas  the  upper  part  of  the 
femoral  has  a  verj^  abundant  collateral  circulation.  For  this  reason  in  pre- 
antiseptic  days  ligation  of  the  femoral  just  below  Poupart's  ligament  was 
avoided  whenever  possible.  The  collateral  circulation  is  so  free  at  this  point 
that  formation  of  a  thrombus  is  prevented  or  retarded  and  as  suppuration 
usually  took  place  in  those  days,  secondary  hemorrhage  would  occur  in  about 
half  of  all  cases;  consequently,  the  external  iliac  whose  branches  are  few 
could  be  ligated  much  more  safely.  With  absorbable  ligatures  and  careful 
asepsis,  these  objections  are  no  longer  so  serious. 

In  aneurisms  of  the  upper  or  common  femoral  it  is  exceedingly  difficult 
to  obtain  even  temporary  hemostasis  unless  the  same  measures  are  employed 
as  in  aneurisms  of  the  iliac ;  that  is,  direct  compression  of  the  abdominal  aorta 
or  the  common  iliac  after  opening  the  abdomen.  The  communications  of  the 
profunda,  which  is  almost  always  in  the  sac  of  an  aneurism  in  this  region, 
together  with  other  collateral  branches  make  the  field  very  vascular.  The 
necessity  for  controlling  bleeding  by  intraabdominal  pressure  on  the  iliac  in 
such  cases  should  be  seriously  considered  whenever  it  is  desired  to  open  the 
sac  of  an  upper  femoral  aneurism. 

Aneurism  of  the  branches  of  the  internal  iliac  practicalbv  alwaj's  occurs 
either  outside  of  the  pelvis  or  else  partly  without  and  partly  within  the  pel- 
vis. It  usuall.y  involves  the  sciatic  or  the  gluteal  arteries.  Formerly,  the 
most  satisfactory  treatment  was  the  method  of  Antyllus,  in  vrhicli  the  vessel 
is  ligated  both  proximally  and  distally  and  the  sac  incised.  The  better  method 
is  endo-aneu/ismorrhaphy  with  either  temporary  or  permanent  closure  of  the 
internal  iliac  by  ligature.  When  the  aneurism  begins  in  the  pelvis,  which  is 
very  unusual,  merely  ligating  the  internal  iliac  may  be  all  that  is  necessary. 

Aneurism  of  the  lower  femoral  can  be  treated  most  satisfactorily  by  endo- 
aneurismorrhaphy  and  here  as  elsewhere  the  obliterative  operation  is  better 
than  the  reconstructive.     If  after  testing  the  collateral  circulation  it  appears 


ANEURISMS 


l:U 


deficient  and  tlio  patient's  condilion  is  otlierwise  good,  the  possibility  of  excising 
the  aneurism  and  Rnl)sti1nrm<i'  a  piece  of  the  saphenous  vein  from  the  other 
leg  slionld  1)0  considered.  The  aluiHinnni  ])i\n(\  may  be  used  with  advantage 
before  resorting  to  a  more  radical  operation. 

Popliteal  aneurisms  may  involve  the  whole  of  the  artery  in  the  later 
stages,  but  in  the  early  stages  they  are  often  of  the  saccular  form  in  which  a 
very  small  portion  of  the  artery  is  affected.  In  several  instances  the 
aneurism  has  been  excised  and  the  ends  of  the  artery  were  united  by  end-to-end 
suture.  Aneurisms  arising  from  the  upper  part  of  the  popliteal  are  much  less 
likely  to  cause  gangrene  than  those  from  the  lower  portion  of  this  arter}-, 
because  most  of  the  collateral  circulation  from  the  articular,  azygos,  and  mus- 
cular branches  opens  into  the  lower  portion  of  the  popliteal.  The  former 
treatment  of  popliteal  aneurism  was  peculiarly  unsuccessful.     Various  meth- 


69. — Traumatic    aneurism    of    the    tem- 
poral  artery. 


Fig.    70. — The  excised  sac  of  the  traumatic  aneurism  shown 
in  Fig.   69.     Note  the  afferent  and  efferent  vessels. 


ods  of  ligation  have  been  used.  As  popliteal  aneurisms  comprise  about  one- 
third  of  all  aneurisms,  excepting  those  of  the  aorta,  the  clinical  material  for 
operative  treatment  of  aneurism  has  been  largely  drawn  from  those  of  the 
popliteal  type.  Of  the  various  methods  of  ligation  the  Hunterian  has  been 
the  most  popular,  but  the  radical  operation  consisting  either  of  extirpation  of 
the  sac  or  the  operation  of  Antyllus,  a  distal  and  a  proximal  ligature  and  in- 
cision of  the  sac,  has  given  better  results.  Endo-aneurismorrhaphy  is  pecul- 
iarly applicable  to  popliteal  aneurisms  and  in  sixty-two  cases  there  was  only 
one  death  wdiich  was  due  to  tetanus  and  two  cases  of  gangrene,  and  in  both 
of  these  instances  the  vein  that  accompanied  the  artery  was  injured  and  had 
to  be  ligated.  This,  of  course,  was  not  a  fault  of  the  method.  In  all  others 
recovery  occurred.  There  was  secondary  hemorrhage  and  relapse  in  four 
eases,  but  in  these  the  reconstructive  method  was  used,  proving  the  Avisdom 
of  adopting  the  obliterative  type  of  endo-aneurismorrhaphy. 

Aneurisms  of  the  smaller  arteries,  such  as  the  radial,  ulnar  or  tibial  ar- 


132 


OPF.RATIVK    SrRGERY 


teries  are  satisfactorily  treated  hy  extirpation  of  the  aiieurismal  sac  Avitli 
double  ligation  of  the  artery.  The  circulation  from  the  companion  artery 
is  usually  so  abundant  and  the  control  of  hemorrhage  by  a  tourniquet  during 
the  operation  is  so  satisfactory  that  this  method  offers  not  only  radical  but 
safe  treatment. 

As  a  result  of  experience  in  the  World  "War  some  surgeons  have  begun  to 
regard  the  direct  suturing  of  the  aneurismal  vessel  as  a  more  satisfactory  op- 
eration than  ligation.  Thus  von  Haberer'^  has  reported  forty-two  operations  for 
aneurism  in  which  he  did  ligation  and  extirpation  of  the  sac  in  twenty-nine 
cases  and  sutured  the  artery  in  thirteen  cases.  He  concludes  that  suture  is 
the  operation  of  choice  whenever  it  can  be  performed.  In  many  instances 
it  is  impossible  to  suture.  Five  of  Haberer's  cases  were  lateral  suture,  one 
of  these  being  on  the  common  carotid  and  two  on  the  subclavian  arteries. 
In  seven  cases  there  was  resection  and  end-to-end  suture,  four  of  these 
being  in  the  femoral  artery,  one  in  the  brachial  and  two  in  the  subclavian. 


Fig.    71. — The    second   case   of   traumatic    aneurism 
of  the  temporal  artery. 


Fig.    72. — Drawing    of    the    excised    sac    shown    in 
Fig.  71. 


Of  the  twenty-nine  cases  in  which  ligation  was  done  amputation  was  neces- 
sary ill  two  patients  and  one  died  of  hemorrhage  from  erosion.  All  of  the 
thirteen  cases  in  which  the  artery  was  sutured  recovered  without  complication. 

The  aneurisms  which  Haberer  treated  resulted  from  Avounds.  Here,  of 
course,  the  arteries  are  supposed  to  be  healthy  and  suturing  in  all  probability 
can  be  carried  out  with  much  greater  prospect  of  success  than  in  the  so-called 
idiopathic  aneurisms  that  result  from  disease  of  the  vessel  wall.  Then,  too, 
the  traumatic  aneurisms  encountered  in  military  surgery  are  in  all  proba- 
bility the  late  results  of  a  pulsating  hematoma  or  in  reality  are  false  aneurisms. 

There  a^e  a  few  cases  on  record  of  aneurisms  of  the  temporal  artery 
which  follows  an  injury  to  the  head.  They  are  small  pulsating  tumors,  and 
have  all  the  characteristics  of  a  miniature  aneurism.  They  are  best  treated 
by  excision  and  ligation  of  the  arteries  on  both  sides*  (Figs.  69,  70,  71  and  72). 


^Wien.  klin.  Wchnschr,  1915,  xxviii,  435,  471;  Abstracts  of  War  Surgerv,  St.  Louis,  1918,  C.  V. 
Mosby  Co.,  p.  273. 

*Horsley,  J.  Shelton:  Traumatic  Aneurism  of  the  Temporal  Arterv,  Ann.  Surg.,  March,  1917,  pp. 
317-320. 


CHAPTER  X 
ARTERIOVENOUS  ANEURISM 

All  arteriovenous  aneurism  is  a  lesion  in  wliicli  there  is  a  comniunication 
between  an  artery  and  a  vein.  The  vein  may  be  a  sinus  in  the  dura  mater. 
There  are  two  forms  of  this  aneurism;  varicose  aneurism,  in  Avhich  the 
communication  between  the  artery  and  the  vein  is  indirect  and  a  sac  exists 
between  the  two  vessels;  and  aneurismal  varix,  in  which  the  blood  flows  di- 
rectly through  the  opening  from  the  artery  into  the  vein.  There  are  many 
combinations  such  as  a  sac  in  the  artery  opposite  the  opening  into  the  vein 
or  there  may  be  two  sacs,  one  in  the  artery  opposite  the  opening  and  one  be- 
tAveen  the  artery  and  the  vein.  The  vein  becomes  dilated,  particularly  the 
proximal  vein,  unless  the  parts  around  it  form  a  firm  support.  Dilatation  of 
the  vein  is  called  varicose  aneurism  by  dilatation.  Secondary  arteriovenous 
aneurisms  are  found  in  the  region  of  the  heart  and  around  the  aorta  where 
a  preexisting  aneurism  has  ruptured  into  a  vein.  The  most  frequent  cause  of 
arteriovenous  aneurism  is  trauma,  a  gunshot  wound  being  the  common  form 
of  traumatism.  The  modern  bullet  which  makes  a  small  puncture  is  very 
likely  to  cause  an  injury  of  this  nature.  Formerly,  when  bleeding  was  in 
vogue,  arteriovenous  aneurism  at  the  elbow  Avith  a  communication  between 
the  brachial  or  the  ulnar  artery  and  a  vein,  was  comparatively  frecpient. 
Fractures,  stabs,  or  indirect  injuries  may  also  result  in  arteriovenous  aneu- 
risms, but  occasionally  it  occurs  spontaneously,  which  is  rare  and  is  probably 
due  to  some  degeneration  in  the  Avail  of  the  artery  that  permits  perforation 
at  this  point.  The  distal  portion  of  the  artery  becomes  contracted  and  nar- 
row since  it  is  subject  to  less  than  its  normal  pressure  as  a  portion  of  the  blood 
intended  for  it  is  delivered  to  the  vein.  The  central  segment  of  the  artery, 
hoAvever,  is  much  dilated.  This  Avas  supposed  at  one  time  to  be  due  to  a  kind 
of  atrophy  and  thinning  of  its  walls,  but  it  is  noAV  believed  to  be  a  genuine 
hypertrophy  of  the  vessel  itself  in  an  effort  to  bring  enough  blood  to  the  seat 
of  the  lesion  to  supply  the  distal  parts  satisfactorily  even  in  the  presence  of 
the  leak  into  the  vein.  The  vein  is  also  dilated  distally  up  to  the  first  valve 
and  centrally  for  a  much  longer  distance.  Sometimes  the  valves  in  the  large 
veins  are  forced  by  the  pressure  of  the  blood  stream  or  by  damming  back  of 
the  blood  and  a  large  varicose  tumor  may  result.  The  dilatation  of  the  vein 
is  much  influenced  by  the  surrounding  tissue.  The  vein  gradually  thickens 
and  becomes  more  and  more  like  an  artery. 

OAving  to  the  activity  of  the  circulation  in  arteriovenous  aneurisms  and 
the  great  difference  in  pressure  betAveen  the  venous  and  the  arterial  trunks, 
clots  rarely  form  and  the  prospect  of  spontaneous  cure  by  clotting  is  very 

133 


134  OPERATIVE   SURGERY 

slight  indeed.  The  liability  to  rupture  depends  to  a  large  extent  upon  the 
size  and  location  of  the  sac.  An  aneurismal  varix  rarely  ruptures.  Some- 
times the  crowding  of  the  arterial  blood  into  the  vein  causes  swelling  from 
damming  back  of  the  venous  blood,  and  at  the  same  time  nutritional  disturb- 
ances may  appear  because  too  little  blood  enters  the  artery  distal  to  the  lesion. 
All  of  these  things,  however,  depend  entirely  upon  the  location  of  the  arterio- 
venous aneurism  and  upon  the  size  of  the  opening.  A  very  small  leak  will  in- 
terfere but  little,  whereas  a  larger  one  may  switch  back  so  much  of  the  blood 
that  nutrition  is  greatly  imj)aired.  In  large  arteries  an  opening  of  considerable 
size  may  cause  so  much  pressure  in  the  venous  system  as  to  produce  dilatation 
or  hypertrophj^  of  the  heart.  Probably  some  arteriovenous  aneurisms  grad- 
ually close  without  any  surgical  intervention.  In  experimental  lateral  arte- 
riovenous anastomosis  in  dogs,  this  tendency  to  closure  is  marked.  When 
this  lesion  occurs  in  the  smaller  arteries,  watchful  waiting  will  be  the  best 
treatment.  If,  however,  the  opening  unites  large  vessels  and  if  it  is  wide, 
permanent  injury  may  be  done  to  the  heart,  and  it  seems  that  such  cases 
should  be  operated  upon  before  the  heart  is  damaged.  If  not  operated  upon, 
the  patient  should  rest  in  bed  and  use  measures  that  tend  to  reduce  blood 
pressure. 

The  arteriovenous  aneurism  may  appear  immediately  after  the  injury  or 
after  the  lapse  of  some  days  or  weeks.  Cases  are  reported  in  which  the 
symptoms  occur  months  or  years  after  the  injury,  but  this  is  unusual  and  is 
probably  due  to  yielding  of  the  scar.  Usually  the  clots  and  the  pressure  from 
the  surrounding  exudate  will  prevent  a  free  communication  for  several  days. 

It  has  been  the  experience  of  many  surgeons  who  have  had  considerable 
clinical  material,  that  unless  there  is  grave  danger  it  is  better  not  to  operate 
upon  these  injuries  too  scon.  The  patient  is  given  the  benefit  of  rest  and  kept 
as  quiet  as  possible  to  reduce  blood  pressure.  Treatment  is  continued  for 
tAvo  or  three  months  after  the  injury  unless  there  is  a  marked  tendency  for 
the  lesion  to  become  worse.  At  this  time  whatever  sac  maj^  have  formed  will 
be  firmly  organized  and  the  collateral  circulation  will  be  amply  established. 

If  the  injury  can  be  recognized  at  once  and  the  surroundings  are  satis- 
factory for  immediate  operation,  it  would  seem  best  to  operate  as  soon  after 
the  injury  as  possible.  The  vessels  should  be  sutured  according  to  the  technic 
described  in  the  chapter  on  Blood  Vessel  Suturing.  Undoubtedly  this  is  the 
ideal  technic.  Unfortunately,  however,  most  of  these  cases  occur  in  military  sur- 
gery and  the  conditions  of  warfare  do  not  often  permit  such  immediate  treat- 
ment. If  operation  cannot  be  done  Avithin  a  few  hours  or  at  least  a  few  days 
after  the  injury  it  is  better  to  postpone  the  operation  for  several  weeks  be- 
cause the  pre'ssure  of  the  hematoma,  the  swelling  and  the  changes  in  the  tis- 
sues such  as  exudate  and  leucocytic  infiltration  subsequent  to  the  injury,  soon 
impair  the  vessel  wall  so  that  it  i^  difficult  for  sutures  to  hold.  After  this 
period  has  passed,  which  may  occur  in  a  few  weeks,  the  tissues  have  again 
become  firm  and  tough  and  suturing  may  be  undertaken  with  safety.  The 
disadvantage,  however,  is  that  the  scar  tissue  makes  the  vessel  walls  tough. 


ARTERIOVENOUS    ANEURISMS  135 

and  it  is  dilTii-iiK  or  impossible  to  use  fine  arterial  needles,  so  it  may  become 
necessary  eitlier  to  resect  tbe  affected  portion  ot:  the  vessel  and  transplant  a 
vein  or  to  resort  to  seme  method  of  ligation. 

Immediately  afti^r  the  injury,  if  operation  cannot  be  done,  pressure  over 
the  lesion  and  on  the  main  artery  by  a  firm  dressing  and  bandage  and  abso- 
lute rest  are  indicated.  The  various  methods  of  ligation,  except  ligations  close 
to  the  lesion,  have  not  proved  very  satisfactory.  Proximal  ligation  is  often 
followed  by  recurrence  and  distal  ligation  alone  is,  of  course,  never  indicated. 
Quadruple  ligation,  tying  artery  and  vein  both  above  and  below,  with  or 
without  extirpation  of  the  sac  has  cured  most  cases,  but  it  is  often  followed 
by  gangrene  if  the  ligatuies  are  not  placed  close  to  the  lesion. 

The  ideal  treatment  is  restoration  of  the  lumen  of  both  the  artery  and 
the  vein.  The  method  of  Matas,  restorative  endo-aneurismorrhaphy,  may  be 
practiced  in  many  cases.  In  the  technic  for  operation  on  aneurismal  varix, 
as  evolved  by  Matas  and  Bickham,  after  temporary  hemostasis  the  vein  is 
opened  and  the  opening  in  the  artery  is  sutured  with  curved  needles  as  in  the 
restorative  aneurismorrhaphy.  The  vein  is  ligated  above  and  below  the  lesion 
and  the  walls  of  the  intermediate  venous  segment  are  sutured  in  layers  as  a 
reinforcement  over  the  closed  arterial  opening.  This  can  be  safel}'  done  for 
the  vein  in  this  condition  does  not  function  as  a  vein  because  of  the  pressure 
of  arterial  blood,  whereas  in  a  simple  arterial  aneurism  injury  to  the  accom- 
panying vein,  which  is  normal  in  function,  may  result  in  a  dangerous  passive 
hyperemia. 

If  it  is  possible  to  secure  complete  hemostasis  an  operation  that  may  be 
done  is  to  dissect  free  both  the  artery  and  vein  and  to  suture  the  wound  in 
each  vessel,  following  the  technic  of  arterial  suturing.  This,  of  course,  would 
necessitate  the  edges  of  the  wound  in  the  artery  and  vein  being  carefully  cut 
awa}^  with  sharp  scissors,  the  adventitia  removed,  and  the  wound  approx- 
imated according  to  the  technic  of  suturing  lateral  or  transverse  wounds 
in  blood  vessels.  Usually  so  much  scar  tissue  has  formed  in  the  arterial 
walls  around  the  opening  that  the  fine  arterial  needles  cannot  be  used  and 
coarser  needles  and  thread  may  result  in  too  much  leakage.  As  much  tis- 
sue as  possible  should  be  preserved  so  that  a  double  mattress  stitch  may  be 
used,  approximating  accurately  the  intima  and  at  the  same  time  not  sacrific- 
ing the  lumen.  The  dilatation  of  the  blood  vessels  toward  the  heart,  together 
with  the  contraction  below  the  lesion,  places  considerably  more  strain  upon 
the  sutures  than  would  be  after  a  wound  of  a  normal  vessel.  This  strain 
should  be  relieved  by  the  application  of  a  strip  of  fascia,  a  large  absorb- 
able ligature,  the  aluminum  band  or  by  infolding  the  artery  according 
to  Matas  and  Allen,  in  order  partly  to  occlude  the  vessel  proximal  to  the 
lesion;  or  a  ligature  may  be  thrown  around  the  artery  with  instructions 
to  tie  it  quickly  if  secondary  hemorrhage  occurs.  If  there  is  no  infection 
the  danger  from  secondary  hemorrhage  is  over  in  a  week  or  ten  days. 

When  it  is  impossible  or  impracticable  to  secure  complete  hemostasis  by  a 
tourniquet  the  problem  is  much  more  difficult.     If  the  nutrition  of  the  limb 


136 


OPERATIVE   SURGERY 


is  seriously  affected,  or  if  the  heart  shows  signs  of  failing  under  extra  strain 
on  the  venous  side,  operation  should  be  attempted.  In  a  heart  that  is  already 
incompetent,  pressure  upon  the  aorta  or  ligation  of  a  large  vessel  might  re- 
sult disastrously  and  the  safer  method  under  such  circumstances  would  be  to 


Fig.    IZ. — The   author's   forceps   for   lateral    bl'i.,,1   v( 
suturing  or  for   certain   cases  of  arteriovenous  aneurism. 


Fig.  74. — ^Method  of  applying  the 
forceps.  The  blades  are  soft  and  it  is 
not  always  essential  to  cover  the  blades 
with    rubber    tubes. 


Fig.     75. — The    vein     and     artery     have    been" 
claniiied  with  the  forceps  and  their  communication 
is   about   to    be   severed. 


Fig.   76. — The  communication   between   the  ar- 
tery   and    vein    has    been    severed    and    is    being 

svitured. 


reestablish  the  circulation  in  both  the  artery  and  the  vein.  Here  it  may  be 
possible  to  dissect  both  vessels  carefully,  exposing  the  lesion,  and  to  grasp 
the  artery  and  vein  with  curved  forceps  for  lateral  suture  of  blood  vessels 
(Figs.  73'  and  74).  After  grasping  the  artery  and  vein  their  communication 
is  severed,  the  edges  of  the  wound  in  the  vessels  are  properl}^  trimmed,  and 


ARTKKlOVKXOrS    ANKTRISMS 


137 


^vitli  a  rolibler's  stitch  in  straight  arterial  needles  or  an  overhand  sliteh  in  a 
curved  needle,  the  openinj^'  in  the  artery  and  then  in  the  vein  is  closed  (Figs. 
75  and  76).  If  it  does  not  cause  too  much  constriction  of  the  lumen,  a  con- 
tinuous reinforcing  stitch  may  be  placed  over  this.  The  lumen  of  the  artery 
should  he  partially  occluded  on  the  cardiac  side,  as  already  mentioned.    Often 


Fig.    n . — Arteriovenous    aneurism    of    the    left    femoral,    near    I'uuijart's    ligament. 


the  tissues  are  too  tough  to  use  arterial  needles  and  curved  French  intestinal 
needles  may  be  employed. 

In  practical  experience  the  late  cases  of  arteriovenous  aneurism  are  often 
best  treated  by  ligation  if  the  ligatures  are  applied  close  to  the  lesion.  Sutur- 
ing the  defect  in  the  vessel  wall  after  a  few  weeks  is  a  difficult  or  impossible 
task  with  a  regular  arterial  needle  and  it  is  doubtful  if  resection  of  the  ves- 
sels and  transplantation  of  a  segment  of  vein  is  justifiable  except  in  very  rare 
instances.     The  vein  does  not  function  as  a  vein,  for  the  arterial  pressure  pre- 


138 


OPERATIVE    SURGERY 


vents  it,  so  there  is  not  the  same  clanger  of  tying  it  here  as  tliere  wonld  1)e  in  an 
arterial  aneurism. 

Among  the  larger  vessels,  the  upper  femoral  region  is  the  most  fre- 
quent site  of  arteriovenous  aneurism  (Fig.  77).  This  region  offers  many 
difficulties  in  treatment  because  of  its  well-known  vascularity  and  especially 
because  of  the  collateral  blood  supply  that  comes  from  behind  the  artery 
through  the  deep  femoral  or  through  some  of  the  internal  branches  of  the 
femoral  itself.     The  great  enlargement  of  the  veins  from  the  pressure  of  the 


Fig.    78.— The   communication  between   these  vessels   was   separated   and   sutured   but   the    tissues   \yere   thick 
and   the   suturing  was  not   satisfactory.     Ligatures   were   applied,   as   shown   in   the    illustration. 

arterial  blood  in  this  neighborhood  also  adds  to  the  difficulties.  The  veins  in 
arteriovenous  aneurisms  in  this  region  are  sometimes  exceedingly  friable. 
In  this  location  it  is  impossible  to  use  a  tourniquet  satisfactorily,  as  it  is  too 
near  Poupart's  ligament.  Hemorrhage  has  to  be  controlled  either  by  careful 
dissection  or  by  a  laparotomy  and  pressure  upon  the  external  iliac  artery 
or  upon  the  aorta  itself.  There  is  a  serious  objection  to  the  latter  method, 
because  pressure  upon  the  aorta  greatly  increases  blood  pressure  and  throws 
extra  strain  upon  an  already  damaged  heart.     Pressure  upon  the   external 


ARTERIOVENOUS    ANEURISMS  139 

iliac  W(nild  1)C  less  trying'  \i|)()ii  llic  lirart,  hut  it  does  not  entirely  cut  ofi:  the 
blood  supply  to  the  al^'eeted  region,  ^vhich  may  not  only  go  through  the  deep 
epigastric  vessels,  as  Avhen  the  aorta  is  occluded,  but  also  through  the  free 
communications  with  many  of  the  branches  of  the  iliacs  of  the  other  side. 
Probably  the  best,  though  the  most  tedious,  nu'tliod  is  to  dissect  the  vessels 
carefully  and  put  a  soft  clamp  on  the  artery  and  vein  above  and  below  the 
lesion,  or  if  the  opening  is  small  and  readily  exposed  the  clamps  for  lateral 
blood  vessel  suturing  may  be  used. 

The  ideal  method  in  any  operation  is  to  restore  tissues  as  nearly  as  possi- 
ble to  their  normal  condition,  provided  this  can  be  done  without  too  great 
risk  to  the  patient's  life.  In  other  regions  where  the  peculiar  vascularity  and 
the  marked  blood  suppl,y  from  behind  are  lacking,  undoubtedly  a  more  favor- 
able opportunity  will  be  found  for  suturing  the  vessels  and  restoring  their 


Fig.    19. — Method    of    applying    ligatures    in    arteriovenous    aneurism.      A    quintuple    ligature. 

normal  caliber.  Theoretically,  this  can  be  done  in  the  upper  femoral  region, 
but,  as  a  matter  of  fact,  in  two  of  my  cases  of  arteriovenous  aneurisms 
within  two  or  three  inches  of  Poupart's  ligament,  where  the  application 
of  a  tournicjuet  interferes  with  the  operation,  I  have  failed  to  reestablish  the 
caliber  by  suturing  (Fig.  78).  The  failure  was  due  to  several  things:  first  of 
all,  the  vascularity  of  the  posterior  portion  of  the  arteriovenous  aneurism, 
which  makes  the  necessary  separation  and  mobilization  of  the  vessels  for  su- 
turing difficult  and  even  dangerous ;  second,  the  friability  of  the  new  veins 
and  tissues;  third,  the  amount  of  scar  tissue  around  the  margins  of  a  large 
opening;  fourth,  the  free  collateral  circulation.  On  account  of  the  normal 
vascularity  of  this  region,  collateral  circulation  is  abundant  after  an  arterio- 
venous aneurism. 

Probably  the  most  satisfactory   operation  for   arteriovenous   aneurism   in 
the  upper  femoral  region  is  a  quadruple  ligation  as  close  as  possihie  to  the 


140  OPERATIVE    SURGERY 

lesion,  together  with  one  other  ligature,  making  a  quintuple  ligation,  in  which 
a  ligature  of  stout  catgut  passes  under  both  artery  and  vein,  both  above  and 
below  the  lesion  and  is  tied  en  masse  under  these  vessels  so  as  to  occlude  the 
posterior  circulation.  (Fig.  79.)  If  this  is  not  practicable  on  account  of  the 
large  mass  of  tissue,  a  stout  catgut  ligature  may  be  passed  in  the  form  of  an  X 
under  the  artery  and  vein  just  above  the  aneurism,  then  the  long  end  from  the  ar- 
terial side  is  carried  over  the  site  of  the  lesion  to  the  venous  side  and  passed 
under  the  vein  and  artery  just  below  the  lesion.  The  two  ends  are  tied  firmly, 
which  makes  the  ligature  in  the  form  of  an  X  and  will  tend  to  occlude  the  pos- 
terior circulation  to  the  aneurism  (Fig.  79). 

The  success  of  these  ligatures  depends  largel}^  upon  a  careful  dissection 
of  the  arteriovenous  aneurism,  taking  great  care  to  preserve  the  collateral 
circulation  and  to  place  the  ligatures  so  close  to  the  lesion  that  no  collateral 
arterial  branches  will  be  closed.  This  not  only  adds  to  the  prospects  of  cure, 
but  lessens  the  strain  on  the  heart. 


CHAPTER  XI 
OPERATIONS  FOR  REPAIR  OF  NERVES 

Operations  on  the  nerves  for  the  restoration  oi:  their  function  nniy  be 
divided  into  neurolysis  and  nerve  suturing.  Neurolysis  consists  of  freeing 
a  nerve  from  sear  tissue.  Suturing  nerves  may  be  the  direct  suturing  of 
divided  nerves  end-to-end,  or  the  interval  may  be  bridged  by  a  graft  of  nerve 
tissue.  This  is  either  turned  as  a  flap  from  the  proximal  or  distal  portion  of  the 
nerve  or  a  free  transplant  of  nerve  tissue  may  be  taken  from  some  uninjured 
nerve,  or  a  tube  of  tissue  may  be  made  to  connect  the  ends  of  the  nerve.  An- 
other method  consists  in  the  implantation  of  the  distal  portion  of  the  injured 
nerve  into  a  sound  nerve  that  has  tlie  same  type  of  function. 

There  is  some  difference  of  opinion  among  neurologic  surgeons  as  to  the 
technic  and  to  some  extent  as  to  many  of  the  principles  of  nerve  suturing. 
This  may  be  expected  because  of  the  high  degree  of  complexity  of  nerve  tis- 
sue and  the  difficulty  with  which  the  regeneration  of  nerves  can  be  satisfac- 
torily demonstrated.  Some  histologists,  for  instance,  claim  that  practically  all 
nerve  tissue  is  regenerated  from  the  central  stump,  and  others  hold  that  the  distal 
stump  takes  an  important  part  in  the  repair. 

Recent  work  in  the  regeneration  of  severed  nerves  seems  to  show  that 
while  the  central  stump  is  the  chief  factor  in  nerve  regeneration  the  distal 
stump  also  has  an  important  part.  The  excellent  work  of  Kirk  and  Lewis  has 
thrown  considerable  light  upon  the  subject.  They  have  shown  that  proto- 
plasmic bands  are  formed  by  the  proliferation  of  the  neurilemma  cells,  and 
that  wdiile  these  bands  come  from  both  the  central  and  distal  stumps,  the 
greater  portion  is  from  the  central  end  of  the  nerve.  All  of  these  protoplas- 
mic bands  seem  to  form  conduits  down  which  the  new  axis  cylinders  grow. 
All  axis  cylinder  formation,  however,  comes  from  the  central  end  of  the  nerve. 
Sometimes  several  axis  cylinders  or  axons  follow  a  single  protoplasmic  band. 
Frequently  many  of  them  do  not  enter  the  distal  nerve  stump,  but  will  curl  up 
on  the  proximal  side  and  form  an  enlargement,  a  so-called  neuroma.  A  neu- 
roma consists  largely  of  the  connective  tissue  multiplication  from  the  sheatli  of 
the  nerve  fibers  into  which  the  axis  cylinders  have  grown  or  have  become  entan- 
gled. Sometimes  the  connective  tissue  may  be  so  dense  as  practically  to  destroy  the 
axons.  In  a  completely  divided  nerve  the  neuroma  on  the  central  end  is  much 
more  prominent  than  that  on  the  distal  end,  because  on  the  central  end  the 
axons  in  their  efforts  to  reach  the  distal  stump  become  entangled  in  the  con- 
nective tissue  proliferation  and  produce  an  enlargement  with  considerable 
regularity.  In  the  distal  portion,  however,  a  neuroma  consists  only  of  the  connec- 
tive tissue  proliferation,  in  which  the  degenerated  axis  cylinders  that  existed 

141 


142  OPERATIVE    SURGERY 

after  the  injury  become  entangied,  as  there  is  no  true  regeneration  of  the  axis 
cylinder  in  the  distal  stump  unless  it  has  been  connected  directly  with  the 
central  stump.  No  regeneration  can  occur  except  in  nerves  that  have  a  neuri- 
lemma, or  sheath  of  Schwann.  The  medullary  sheath  is  not  essential  to  regen- 
eration. The  neurilemma  cells  take  a  most  active  part  in  regeneration  and 
though  they  seem  only  to  form  conduits  through  which  axons  grow  from  the 
central  end  of  the  nerve,  these  conduits  appear  to  be  essential  to  the  growth  of 
the  axons. 

There  are  more  axons  than  central  nerve  cells  because  some  axons  branch. 
Wlien  this  branching  occurs  it  is  always  at  a  node  of  Ranvier.  Thus'  a  nerve 
cell  that  has.  two  axons  may  function  even  if  one  of  them  is  destroyed. 

Nerves  histologically  similar  often  regenerate  with  different  degrees  of 
readiness.  The  sensory  fibers  of  the  fifth  nerve  regenerate  rapidly  and  per- 
fectly, while  a  mixed  or  motor  nerve  regenerates  with  much  more  difficulty. 
There  are  also  differences  in  the  readiness  of  repair  of  many  mixed  spinal 
nerves. 

It  is  important  to  bear  in  mind  these  facts  in  order  to  conceive  the 
objects  of  nerve  suturing.  In  such  delicate  tissue  as  nerves  it  is  natural  to 
expect  that  the  greatest  gentleness  must  be  used  in  any  surgical  manipula- 
tion. In  the  limbs  it  is  best  to  do  the  operation  without  a  tourniquet  for  three 
reasons:  (1)  the  pressure  of  the  tourniquet  may  bruise  the  nerve,  (2)  the 
tissues  in  the  region  of  the  operation  and  distal  to  the  tourniquet  are  deprived 
of  their  nutrition  during  the  application  of  the  tourniquet,  and  (3)  there  is 
great  likelihood  of  excessive  oozing  in  the  operative  field  after  the  tourniquet 
has  been  removed. 

No  attempt  should  be  made  to  expose  the  nerve  at  the  site  of  injury  until 
after  it  has  been  thoroughly  uncovered  in  its  healthy  portion,  both  central 
and  distal  to  the  injury.  The  nerve  should  not  be  handled  if  it  is  possible  to 
avoid  it.  The  tissues  are  dissected  away  from  the  nerve  instead  of  dissecting 
the  nerve  away  from  the  tissues.  It  is  important  to  isolate  the  nerve  to  no 
g'reater  extent  than  necessary.  It  must  be  remembered  that  the  regen- 
eration of  the  nerve  Avill  depend  to  some  degree  upon  its-  blood  supply  for  if 
it  is  dissected  too  freely  from  its  surrounding  tissues,  even  though  the  nerve 
suturing  may  be  properly  done,  the  nutrition  of  the  nerve  may  be  so  poor 
that  failure  Avill  result.  It  is  for  the  same  general  reason  that  a  blood  vessel 
should  not  be  dissected  from  its  bed  for  fear  of  interfering  with  the  nutrition 
of  its  walls.  Flaps  in  plastic  work  heal  best,  other  things  being  equal,  when 
there  is  a  good  blood  supply. 

After  the  nerve  has  been  satisfactorily  exposed,  botli  distally  and  proxi- 
mally  to  the  injury,  dissection  is  carried  to  the  point  of  injury  and  this  region  of 
the  nerve  is  mobilized  by  sharp  dissection.  If  it  has  been  determined  that  the 
function  of  the  nerve  is  abolished  and  if  a  sufficient  period  of  time,  four  to  six 
months,  has  been  permitted  to  elapse  since  the  injury  to  the  nerve  without 
reasonable  improvement,  resection  of  the  injured  portion  should  be  seriously 
considered.     If  the  nerve  ends  have  been  completely  divided  and  terminate 


REPAIR    OP    NERVES  143 

ill  lUMironias,  of  course  tlic  union  ol'  the  iioi'vc  by  su1ui'iu<;'  must  Ix'  done. 
In  some  instances,  M'liile  Ihe  eoutiuuity  oh'  the  uei'vc  luis  not  been  destroyed 
the  scar  tissue  has  so  inliltrated  an  injured  segment  of  nerve  as  to  make  it 
functionally  useless,  and  resection  and  suture  are  demanded.  Sometimes  a  neu- 
roma oceui's  on  a  jiortion  of  the  nerve  wliik'  llie  rest  of  the  nerve  is  healthy, 
and  in  such  cases  the  neuronui  can  he  disseeled  away,  leaving  the  healthy 
part. 

In  cutting  away  neuromas  or  scar  tissue  from  the  end  of  a  nerve,  it  is 
highly  important,  as  Dean  Lewis  and  others  have  insisted,  to  remove  all  the 
scar  tissue  and  go  into  healthy  nerve  fibers.  In  order  not  to  waste  useful 
tissue  it  is  best  to  cut  the  scar  tissue  away  in  small  sections  until  normal 
nerves  have  been  exposed.  It  is  utterly  useless  to  suture  a  nerve  that  is 
infiltrated  with  dense  scar  tissue,  and  it  is  better  to  leave  a  considerable  inter- 
val between  two  health}-  nerve  ends  than  to  approximate  neatly  the  ends 
of  nerves  containing  dense  scar  tissue. 

The  nerve  ends  should  never  be  caught  with  forceps  and  should  be  sev- 
ered with  a  sharp  knife.  The  bleeding  in  the  nerve  ends  should  be  thoroughly 
controlled.  In  some  large  nerves,  as  the  sciatic,  the  bleeding  vessel  can  be  demon- 
strated and  caught  with  mosquito  forceps  and  tied  without  injury  to  the  sur- 
rounding nerve  fibers.  Gentle  pressure  of  gauze  for  a  few  minutes  will 
control  slight  bleeding.  If  the  nerve  ends  are  sutured  together  while  bleed- 
ing, or  if  a  hematoma  forms  between  the  nerve  ends,  an  excessive  amount 
of  connective  tissue,  which  is  the  bane  of  nerve  surgery,  may  form. 

The  nerve  ends  should  be  brought  together  end-to-end  and  without  axial 
rotation  so  that  the  ends  of  the  nerve  fibers  in  the  central  stump  will  as  far 
as  possible  be  approximated  to  the  ends  of  corresponding  fibers  in  the  dis- 
tal stump.  All  manipulations  such  as  freeing  the  nerve  and  hemostasis  are  com- 
pleted before  the  nerve  is  divided  or  the  scar  tissue  dissected  away.  The 
injured  portion  of  the  nerve  can  be  siezed  and  traction  made  from  this  por- 
tion, so  avoiding  undue  manipulation  of  the  healthy  nerve  fibers.  It  is 
best  to  leave  a  small  tag  of  scar  tissue  on  each  stump  which  can  be  clamped 
and  will  serve  as  a  handle  to  manipulate  the  nerve  ends  while  they  are 
being  sutured.  This  tag  is  cut  away  after  most  of  the  sutures  have  been 
applied  and  the  nerve  fibers  that  have  been  covered  by  the  tag  are  sutured 
to  the  corresponding  nerve  fibers  on  the  other  side.  In  this  way,  too,  axial 
rotation  is  prevented.  A  suture  of  fine  arterial  silk  near  each  end  of  the  nerve, 
penetrating  only  the  sheath,  may  also  be  used  to  prevent  axial  rotation. 

As  to  suture  material,  either  catgut  or  very  fine  silk  is  used.  If  there 
is  no  great  degree  of  tension,  plain  catgut  should  hold  the  nerve  in  position 
sufficiently  long.  If  it  is  desired  for  the  suture  to  have  a  more  lasting  effect 
mildly  chromicized  or  tanned  catgut  can  be  used.  Fine  black  silk  either 
00  or  arterial  00000  silk,  in  arterial  needles,  which  is  better  still,  is  a  good 
suture  material.  If  the  nerve  is  large,  one  or  two  sutures  of  fine  silk  or 
catgut  are  placed  through  each  nerve  stump.  These  act  as  tension  sutures. 
The  other  sutures   of  arterial  silk   are   inserted  into   the  nerve   sheath   and 


144 


OPERATIVE    SURGERY 


go  a  short  distance  l)elow  the  sheath  so  as  to  catch  a  firm  hold.  Fine  silk, 
preferably  arterial  silk,  is  excellent  for  these  sutures  Avhicli  are  l)est  placed 
as  interrupted  mattress  sutures.  In  larger  nerves  a  contiiuious  suture  of  this 
silk  can  be  used  as  an  epineural  suture  around  the  entire  nerve  sheath  after 
inserting  a  few  interrupted  sutures  as  tractor  sutures.  It  is  important  not 
to  injure  the  nerve  fibers  by  catching  them  in  a  suture,  but  it  is  still  more 
important  to  luive  a  sufficiently  firm  bite  on  tlie  tissues  so  that  the  sutures 
will  not  cut  or  pull  out.  After  inserting  the  cliief  sutures  the  ends  of  the 
nerve  are  approximated  and  held  in  position  by  the  fingers  of  an  assistant 
and  then  the  sutures  are  tied  just  snugly  enough  to  keep  the  ends  of  the 
nerves  Avell  in  apposition  (Fig.  80).  The  assistant  should  not  relax  the  nerve 
ends  until  every  suture  has  been  tied.    In  this  way  undue  tension  on  any  sin- 


Fig.  80. — Appearance  of  nerves  after  suturing. 

gle  suture  is  avoided  and  there  is  less  likelihood  of  the  suture  breaking  or 
pulling  out.  If  the  central  or  tension  suture  appears  unnecessary  after  the 
sutures  in  the  nerve  sheath  have  been  tied,  it  may  be  removed.  Except  in 
the  smallest  nerves,  at  least  three  sutures  should  be  inserted  in  the  sheath 
of  the  nerve.  There  should  be  no  tension  on  the  sutured  nerve.  To  avoid 
this  the  position  of  joints  near  the  sutured  nerve  may  be  utilized.  Thus, 
the  elbow  can  be  flexed  to  relieve  tension  on  the  median  and  musculospiral, 
or  extended  when  the  ulnar  nerve  is  sutured.  The  ulnar  may  l)e  displaced 
to  the  front-  of  the  elbow,  taking  care  not  to  injure  its  muscular  branch  to 
the  flexor  carpi  ulnaris,  and  the  elbow  is  then  flexed. 

There  has  been  much  discussion  as  to  the  prevention  of  adhesions  and 
contraction  at  the  site  of  the  nerve  suturing.  A  variety  of  applications  has 
been  suggested,  including  sections  of  blood  vessels  that  have  been  hardened 
in  formalin  and  various  kinds  of  foreign  bodies,  as  rubber  and  bone  tubes. 


i;i:i'Aii;  of  .\i;kvi:s 


14:) 


II  is  well  1(1  I'dlldW  llic  ^ciicr.-il  principle  not  lo  cliillci'  llic  silc  ol'  (tpcrjil  idii  wilh 
foreigii()i'  cxli'ji  tissue  unless  IIkm-c  is  ;i  disliiiel  henelil  1o  be  derived  from 
it.  If  Ihe  nei'N'es  e;ui  lie  well  ;i  pproxinuiled  iind  if  Hie  site  of  imioii  e;ni  l)e 
])liieed  ill  or  eo\-ered  by  li(>;il1liy  iiuisele,  I'jiseiji  or  I'al,  alont;'  llie  iioriiial 
eourse  ol'  the  iier\-e  and  it'  there  is  no  lar<;'e  amount  of  sear  tissue  in  the  nei<>li- 
borhood,  nothing'  else  is  desired.  J  I!  tlie  ends  of  the  nerves  cannot:  l)e  made 
to  meet,  liowever,  some  form  of  tnbc  construction  prefei'a])ly  a  tul)e  either 
lined  aaIIIi  or  eonstrueted  of  fat  can  l)e  used.  Dean  Lewis  has  secured 
satisfactory  results  with  a  tube  of  fascia  lined  Avith  fat,  fastening  the  ends 
of  tlu^  nerve  that  could  not  be  approximated  into  each  end  of  the  tube. 

If  around  the  site  of  nerve  suturing  there  has  been  consider-able  scar  tis- 
sue, the  sutured  nerve  should  be  jirotected.     This  is  best  done  by  first  dis- 


Fig.    SI.  Fig.    82. 

Fig.   81. — Dissection   of   binding   scar   tissue   from    a   nerve,    with    outline    of   a   pedicle    flap. 
F'ig.   82. — Pedicle  flap   applied   around   the   old   site   of   scar   contraction. 


secting  away  the  scar  tissue  around  the  nerve  as  freely  as  possible,  control- 
ling bleeding,  and  then  shifting  the  nerve  so  it  Avill  lie  in  a  normal  plane  of 
intermuscular  fascia.  If  this  is  impossible  the  sutured  nerve  may  be  protected 
by  a  pedieled  flap  of  fascia  and  muscle  or  fascia  and  fat,  placing  the  fat 
next  the  nerve  (Figs.  81  and  82).  If  the  pedicle  is  well  nourished  the  flap 
will  aid  in  blood  supply  to  the  injured  nerve  and  so  tend  to  avoid  excessive 
scar  tissue  formation.  No  bleeding  surface  such  as  cut  muscle,  should  ever 
be  placed  in  contact  with  the  sutured  nerve.  The  interposition  of  tissue  as 
a  free  graft  around  the  sutured  nerve  tends  to  isolate  the  nerve  from  the 
nutrition  that  can  be  derived  from  the  blood  supply  of  its  adjoining  tissues. 
Every  effort  should  be  made  to  secure  an  end-to-end  union  of  healthy 
nerve  tissue.  If  a  reasonable  dissection  cannot  give  satisfactory  approxima- 
tion, sometimes  a  change  of  position  of  the  limb  will  make  it  possible   to 


1^6 


OPERATIVE    SURGERY 


bring  the  nerve  ends  together.  Thus  the  hand  may  l:)e  flexed  in  suturing  the 
median  nerve  or  the  knee  in  suturing  the  sciatic.  The  limb  must  be  put 
up  in  splints  or  i)laster  of  Paris  and  kept  in  tlie  flexed  position  for  at  least 
two  months  after  the  operation. 

Occasionally,  however,  in  spite  of  manipulation  of  the  nerve  and  of  the 
limb  there  will  be  a  gap  between  the  ends  of  the  nerve,  and  the  problem 
arises  of  what  is  to  be  done  to  bridge  the  defect.  Four  courses  have  been 
recommended:  (1)  suturing  the  ends  of  the  nerve  into  a  tube  of  fat  and 
fascia,  (2)  free  transplantation  of  a  nerve  graft  from  an  uninjured  nerve, 
(3)  transplantation  of  the  distal  end  of  the  nerve  into  another  healthy  nerve 
of  somewhat  similar  function,   and   (4)    flaps  taken  from  the  injured  nerve. 

(1)  This  method  of  using  a  fatty  fascia  tube  and  suturing  the  ends  of  the 
nerve  into  the  tube  so  that  the  fibers  will  more  readily  reunite  has  been  de- 


Fig.    83.  I'ig.    84. 

Fig.   83. — U.Kcision  of   neuromas   from  a  divided   nerve. 

Fig.  84. — Application  of  a  tube  of  fat  and  fascia  between  ends  of  a  nerve  that  cannot  be  approxi- 
mated.     (Method   of   Dean   Eevvis.) 

veloped  by  Dean  Lewis  and  has  given  good  results  in  some  cases  in  his  hands, 
though  its  place  in  surgery  according  to  Lewis  has  not  been  definitely  es- 
tablished (Figs.  83  and  84).  Edinger  states  that  the  fibers  of  human  nerves 
grow  best  in  a  medium  of  agar  and  after  filling  a  segment  of  an  artery  or  a 
vein  with  agar  he  sutures  the  ends  of  the  nerves  into  this  segment.  This 
has  not  proT"ed  satisfactory.  Foreign  material  such  as  rubber  tubes  should 
not  be  usecL 

(2)  A  free  graft  of  a  nerve  may  be  taken  from  a  nerve  of  different 
function.  A  gap  in  a  motor  or  mixed  nerve,  such  as  the  facial  or  musculo- 
spiral,  may  be  bridged  by  a  segment  from  a  purely  sensory  nerve  as  the 
radial  or  the  internal  cutaneous.     A  segment  of  the  nerve  is  removed,  taking 


i;i;i'AIK    OP    XKRVES 


147 


c';ire  tliat  il  sliouhl  ])c  of  ample  Iciiulli  and  sului'cd  to  the  ends  of  the  nerve 
with  llie  same  leehiiic  thai  wmdd  he  used  in  unilinu'  the  nei'X'e  en(hto-end. 
The  g'raft  is  usually  luueh  smaller  than  the  nerve  and  the  supply  of  material 
from  -whieli  the  <iraft  can  he  taken  is  practically  limited  to  the  radial,  in- 
ternal eula neons  or  the  intercostal  nerves.  When  the  dispai'ity  l)etween  the 
size  of  the  graft  and  the  size  of  the  injured  nerve  is  too  great  a  ''cable" 
graft,  made  up  of  several  segments  of  the  nerve  to  be  grafted,  can  be  used. 
The  segments  Avhieh  should  l)e  handled  as  little  and  as  gently  as  possible, 
are  cut  of  the  proper  length,  held  together  at  their  ends  by  sutures  and  then 
transplanted.^  Elsberg  places  these  sutures  before  the  segments  are  cut  as 
shown  in  the  illustration  (Figs.  85,  86  and  87). 

(3)   The  distal  end  of  the  nerve  may  be  transplanted  into  a  neighboring 
nerve  of  scmewliat  similar  function  ;  for  instance,  a  motor  or  a  mixed  nerve 


Fig.    85. — Elsberg's    method    of    cutting    sections 
of  a  small   nerve  for   cable   transplantation. 


Fis;.   86. — Cable    shown    in    Fig.    85    is   being   su- 
tured   into    the    defect    between    the    ends    of    the 


must  always  be  transplanted  into  a  motor  or  a  mixed  nerve.  For  regeneration 
it  is  best  to  transplant  the  nerve  end-to-end,  severing  the  healthy  nerve 
and  uniting  its  central  end  to  the  distal  end  of  the  injured  nerve.  This,  of 
course,  sacrifices  the  function  of  a  healthy  nerve  and  to  overcome  this  some- 
times the  distal  end  of  the  injured  nerve  is  transplanted  into  the  side  of 
the  healthy  nerve,  making  an  end-to-side  transplantation,  or  both  free  ends 
are  transplanted  end-to-side  into  this  nerve  trunk.  Of  course,  in  end-to-side 
implantation  a  Avound  must  be  made  in  the  side  of  the  healthy  nerve  trunk 
that  will  expose  some  of  its  axis  cylinders  (Fig.  88). 

(4)   Bridging  a   defect   in   a   nerve  by  flaps  taken   from   the   ends   of   the 
nerve  is  a  procedure  that  is  probably  without  value,  though  much  interest 


\Tour.  Am.  Med.  Assn.,  Nov.  8,   1919,  pp.   1422-1-127. 


148 


oPERATivi:  srR(;i:in' 


has  recently  been  created  in  this  method  hy  ]\rac'k('nzi(\  who  reported  several 
cases.-  (Fig.  89.)  In  one  patient  a  defect  of  ten  and  three-quarter  inches  in 
the  sciatic  nerve  vas  bridoed  with  flaps  from  the  central  and  the  distal 
ends  of  tlie  nerve.  Byron  Stookey"'  reviews  this  case  carefully  and  shows 
that  the  improvement  was  prohal)ly  duo  to  the  fact  that  flexor  muscles  of 
the  leg,  the  hamstring  muscles,  have  a  double  nerve  supply  and  that  the 
ujDper  supply  vas  never  injured  by  the  resection  of  the  sciatic.  The  technie 
of  making  nerve  flaps  is  such  that  in  making  the  flaps  about  one-half  of  the 
nerve  is  sacrificed.  It  is  not  conceivable  that  the  central  end  of  the  axons 
that  are  divided  when  the  flap  is  cut  from  the  central  stump  can  ever  unite  to  anj^ 
other  axons.  If  the  flap  is  from  the  distal  nerve  stump  it  thus  destroys  a  large 
part  of  tlie  peripheral  distribution  of  the  nerve.    A  reference  to  the  diagram  of 


Fig.   87. — Appearance   of  nerve  after  cable  graft   has  been   completed,   according  to   lilsberg. 


a  nerve  flap  operation  (Fig.  89)  shows  that  the  ends  of  the  axons  are  not  in  con- 
tact and  not  in  the  same  direction  and  it  seems  difficult  or  impossible  for  the  ends 
of  the  central  axons  to  reach  the  ends  of  the  axons  in  the  flap,  and  unless  the  ends 
of  these  axons  unite  there  is  no  regeneration.  It  must  be  borne  in  mind  that  tlie 
histologic  repair  of  the  nerves  is  very  different  from  that  of  other  tissue  such 
as  tendons  and  blood  vessels.  No  new  axons  are  ever  formed  and  all  that  surgery 
can  do  is  to  connect  peripheral  axons  Avith  central  axons  or  to  provide  a  direct 
and  easy  path  for  growth  from  the  central  end.  Experiments  by  Iluber*  show 
there  is  no  regeneration  after  flap  operations  on  dogs. 


=Ann.   Surg.,   1909,  1,  295;   Surg.,   Gynec.   &  Obst.,   Oct.,   1918. 
'Surg.,  Gynec.  &  Obst.,   Sept.,   1919,  pp.   287-312. 
^Surg.,  Gynec.  &  Obst.,  Dec,  1917,  pp.  595-604. 


AIR    OF    N1':RVKS 


14!) 


Moyiiiliaii  is  ([uiU'  posilivc  1h;it  <irafls  and  I  raiisplaiital  ion  of  Die  nerves 
.slioTild  not  ])c  (loiio.  lie  lliinks  thai  only  end-lo-cnd  nnion  is  satisfactory  and 
goes  so  far  as  to  resect  the  bone  of  a  lind)  in  oi-der  to  secure  it.  Other  neuro- 
logic surgeons  do  not  agree  with  him.  I1  is  nndonl)tedly  true  that,  while 
end-to-end  nnion  gix'es  the  best  results  and  transplantation  and  xai'ious 
methods  of  bridging  gaps  have  not  been  anything  like  as  satisfactory  as  the 
end-to-end  nnion,  there  are  still  a  sui^cient  number  of  cases  recorded  to  make 
it  certain  that  some  of  these  methods  that  are  condemned  by  Moynihan  are 
not  Avitho\it  vahu\     For  instance,  there  are  many  cases  in  which  the  distal 


Fig.   88. — ICml-to-side   suturing   of   a   nerve, 

end  of  the  facial  nerve  has  been  implanted  either  into  the  hypoglossal  or  the 
spinal  accessory  and  in  which  the  results  have  been  very  satisfactory.  Thus 
Adson-^  reports  the  final  results  of  anastomosis  of  the  facial  nerve  to  the 
hypoglossal  in  one  case  and  to  the  spinal  accessory  in  eight  cases.  Eight 
of  the  operations  Avere  end-to-end.  The  average  amount  of  motor  return 
estimated  by  quantitative  examination  of  jiower  and  control  of  the  facial 
muscles  was  seventy-one  per  cent  of  the  normal  function  in  this  group  of  cases. 
Much  of  the  disagreement  in  the  value  of  results  of  nerve  suture,  and 
particularly  of  nerve  transplantation,  is  due  to  the  fact  that  some  nerves  re- 
generate  more   promptly   and   more    satisfactorily   than    others,    and   that    in 


•"Ann.    Surg.,   August,    1919. 


150 


OJ'ERATIVK    SrUGKRY 


some  individuals  tlie  nerve  tissne  vill  rep'enerate  very  mneh  better  than  in 
other  individuals.  In  a  young  healthy  child  complete  regeneration  is  much 
more  probable  than  in  an  adult.  Experimental  work  in  lower  animals  may 
show  better  results  in  nerve  surgery  than  are  obtained  clinically,  whereas  in 
tissue  of  less  delicacy  there  is  not  the  same  difference  in  regeneration  between 
lower  animals  and  man. 

The  technic  of  nerve  suturing  that  has  been  deseril^ed  is  applicable  in 


Fig.  89. — The  method   of  bridging  a  defect   in   a   nerve  by  flaps.     The   drawing  shows   the   apparent   impossi- 
bility  of  the  nerve   fibers  regenerating  after  such   a   method. 


any  form  of  nerve  operation,  but  there  are  two  operations  for  injured  nerves 
that  have  been  so  standardized  as  to  make  it  advisable  to  describe  these 
procedures.  The  first  is  the  operation  for  peripheral  facial  paralysis,  and 
the  other  is  the  operation  for  paralysis  folloAving  "injuries  to  the  brachial 
plexus.  This  latter  type  of  paralysis  is  often  found  in  infants  where  it  is  due 
to  injury  of  the  brachial  plexus  resulting  from  prolonged  and  difficult  delivery. 
In  the  operation  for  peripheral  facial  paralysis  it  is  usually  necessary 
to  anastomose  the  distal  end  of  the  facial  nerve  to  some  other  nerve  of  simi- 


lllOrAlR    OF    NKRVKS  151 

lar  fiiiu'lioii.  11  iiiiiy  oi'cjisioiuilly  l)e  ])()ssil)l('  lo  iiuikc  an  eiul-lo-ciid  suture 
of  tlie  i'arial  mn-ve  if  the  injury  occu.rrcd  Ix^twceu  the  emergence  of  the 
nerve  from  llic  slylouiastoid  loranuMi  and  the  point  at  wliidi  its  main  brandies 
are  given  off  in  the  parotid  g^aud.  Sneli  an  injury,  liowcver,  is  rare  aud  tlie 
teeltnieal  dillicultios  of  suturing  would  bo  great.  Practically  all  paralyses  of  the 
facial  nerve  are  dne  to  injury  of  the  nerve  between  its  origin  and  its  emergence 
from  the  stylonmstoid  foramen.  A  large  portion  of  the  injuries  to  this  nerve  are 
sustained  by  that  inn'tion  that  lies  in  its  canal.  At  this  point,  too,  inflammation 
extending  from  the  ear  or  from  the  mastoid  cells  may  cause  such  disease  of  the 
nerve  as  to  produce  paralysis.  Before  operation  is  undertaken  it  should  be 
definitely  ascertained  that  the  distal  portion  of  the  nerve  is  capable  of  conducting 
impulses.    This  can  be  done  by  electrical  tests. 

In  the  operation  for  anastomosis  of  the  facial  nerve  two  nerves  liave 
been  emplo,yed,  the  spinal  accessory  and  the  hypoglossal.  Both  of  these  nerves 
are  motor  in  function  like  the  facial  and  are  in  convenient  proximity  to  the 
facial  nerve.  The  spinal  accessory,  or  11th  nerve,  supplies  the  sternomastoid 
and  trapezius  muscles  while  the  hypoglossal  goes  to  the  muscles  of  the  tongue. 

Some  surgeons  have  found  that  after  anastomosis  of  the  facial  and  spinal 
accessory  the  associated  action  of  the  muscles  of  the  face  and  the  shoulder 
region  are  so  marked  as  to  interfere  materially  with  the  success  of  the  oper- 
ation. For  this  reason  many  surgeons  prefer  to  use  the  hypoglossal  nerve 
instead  of  the  spinal  accessory.  Technically,  there  is  not  much  difference  in 
either  operation  and  the  incision  can  be  the  same.  The  incision  is  made 
along  the  anterior  border  of  the  sternomastoid  muscle,  beginning  in  the 
groove  between  the  external  ear  and  the  mastoid  and  extending  downward 
about  five  inches.  The  ear  is  retracted  forward,  the  fascia  covering  the  mas- 
toid is  incised,  and  the  anterior  border  of  the  sternomastoid  muscle  is  ex- 
posed. With  blunt  dissection  the  incision  is  carried  down  between  the 
parotid  and  the  anterior  border  of  the  mastoid.  The  facial  nerve  is  found 
at  a  depth  of  about  one-half  inch  from  the  surface  of  the  mastoid  process  and  at 
the  junction  of  its  lower  and  middle  thirds.  The  facial  nerve  should  be  dis- 
sected out  gently,  taking  care  to  avoid  catching  it  with  forceps,  and  the  dis- 
section is  carried  back  as  far  as  possible.  In  some  instances,  a  portion  of  the 
mastoid  process  and  temporal  bone  can  be  cut  aAvay  so  that  the  nerve  can  be 
divided  higher  up  in  its  bony  canal.  This,  however,  is  not  necessary  as 
a  rule.  The  facial  nerve  may  be  surrounded  by  a  loose  loop  of  catgut  so  that 
it  can  be  readily  identified,  but  it  should  not  be  divided  until  the  nerve 
into  which  it  is  to  be  implanted  has  been  dissected  free.  It  is  important  to 
dissect  the  facial  nerve  before  proceeding  further  with  the  operation,  because 
cases  have  been  found  in  which  the  facial  was  either  missing  or  converted 
into  a  fibrous  cord.  In'  such  instances,  of  course,  the  operation  would  be 
abandoned.  During  the  whole  of  the  dissection  care  should  be  taken  to  avoid 
soiling  the  Avound  Avith  blood.  The  vessels  should  be  clamped  or  the  oozing 
controlled  by  gauze  compresses. 

The   spinal   accessory   nerve   is   found   by   first   demonstrating   the   trans- 


152 


OPERATIVE    SURGERY 


verse  process  of  the  atlas,  which  is  about  one-half  inch  below  the  mastoid, 
and  then  the  posterior  belly  of  the  digastric  muscle  in  front  of  the  atlas. 
The  spinal  accessory  nerve  lies  between  the  transverse  process  of  the  atlas 
behind  and  the  digastric  muscle  in  front.  The  hypoglossal  ner^'e  is  probably 
more  closely  related  to  the  nerve  centers  of  the  facial  muscles  of  expression 
than  are  the  centers  of  the  spinal  accessory  nerve   (Fig.  90). 

The   hypoglossal   nerve    is    best   located   where   it    crosses    the    external 
carotid  artery  just  below  the  occipital  branch  of  the  external  carotid.     Here 


Fig.   90. — Suturing   the   hypoglossal   nerve   to   the   facial   nerve.      The   spinal   accessory    nerve   is   also    exposed 

in  the  same  drawing. 


the  hypoglossal  nerve  curves  forward  and  to  the  outer  side  of  the  external 
carotid  and  then  it  lies  betAveen  the  posterior  belly  of  the  digastric  muscle 
externall}"  and  the  hypogiossus  muscle  internally.  About  one  and  one-half 
inches  of  the  liypoglossal  nerve  are  dissected  free  and  at  least  one-half  inch  of  the 
facial  nerve.  After  exposing  fully  the  hypoglossal  nerve  the  facial  nerve 
is  cut  as  close  to  its  point  of  emergence  from  the  skull  as  possible.  The 
stump  is  then  drawn  down  and  the  hypoglossal  nerve  is  cut  at  such  a  point 
that  its  central  end  can  easily  be  sutured  to  the  peripheral  end  of  the 
facial  nerve  without  tension.  The  suturing  is  done  with  three  or  more  su- 
tures of  fine  arterial  silk,  using  the  technic  that  has  been  described  in  nerve 


REPAIR    OP    NERVES  153 

suturiiiii'.  Because  these  nerves  are  sniall,  simple  interrupted  sutures  of  ar- 
terial silk  are  best.  If  the  ojieration  has  been  dry  and  if  no  blood  has  been 
permitted  to  smear  the  wounded  nerves,  union  will  prol)al)ly  be  satisfactory. 
It  is  best  to  flnsh  out  the  wouiul  Avith  salt  solution  in  order  to  remove  any  small 
amount  of  blood  tluit  may  have  oozed.  Some  oi^erators  cover  the  site  of 
anastomosis  with  fat  in  order  to  prevent  adhesions.  The  late  John  B..  Mur- 
phy advised  that  the  site  of  the  union  be  buried  in  muscle  tissue,  preferably 
in  the  belly  of  the  stylohyoid  muscle.  If  the  dissection  has  been  carried 
out  carefully  Avithout  the  loss  of  blood  and  if  the  tissues  have  been  handled 
gently  it  is  not  likely  that  cicatricial  contraction  will  occur.  If  any  sub- 
stance is  used  to  protect  the  line  of  anastomosis  it  would  probably  be  best 
to  use  a  pedicle  liap  of  fat  and  fascia.  The  wound  is  closed  l:»y  suturing  it 
lightly,  closing  the  deep  wound  with  a  few  catgut  stitches,  and  the  skin  pref- 
erably Avith  silk  or  silkworm-gut. 

Various  operators  of  experience  have  modified  the  technic  as  described. 
In  some  instances  the  end  of  the  facial  nerve  has  been  implanted  laterally 
into  the  hypoglossal,  after  nicking  the  hypoglossal  slightly.  In  this  manner 
it  has  been  claimed  that  the  function  of  the  hypoglossal  is  not  materially 
interfered  with  and  the  muscles  of  the  tongue  are  not  greatly  affected.  It 
seems,  however,  that  regeneration  of  the  facial  nerve  and  facial  muscles 
is  not  so  complete  after  an  end-to-side  anastomosis  as  after  an  end-to-end  union. 

A.  "W.  Adson,"  of  the  Mayo  Clinic,  reports  that  of  nine  anastomoses  of 
the  facial  nerve  which  have  been  done  at  the  Mayo  Clinic,  eight  have  been 
followed  up  and  examined  at  intervals  after  the  operation  or  have  reported  by 
letter.  One  of  the  nine  patients  has  not  been  heard  from.  The  average 
time  before  improvement  was  noticed  in  these  cases  was  7.9  months  and  the 
average  amount  of  return  of  motor  function  was  about  71  per  cent  of  the 
normal. 

Operations  for  paralysis  of  the  muscles  supplied  by  the  brachial  plexus 
are  often  done  in  infants,  as  this  type  of  injury  frequently  folloAVS  difficult 
labor.  This  injury,  too,  is  not  infrequent  from  blows  on  the  shoulder  or  from 
a  sudden  trauma  that  carries  back  the  shoulder  and  bruises  the  brachial 
plexus  by  the  pressure  of  the  clavicle.  If  the  clavicle  is  fractured,  as  usually 
occurs,  no  harm  is  done  the  plexus,  but  if  the  clavicle  holds,  serious  damage 
may  be  done  to  the  brachial  plexus  which  may  result  in  immediate  paralysis 
of  those  muscles  supplied  by  the  injured  portion  of  the  plexus. 

In  injury  to  the  newborn,  or  so-called  obstetrical  palsy,  there  is  not 
infrequently  a  dislocation  of  the  shoulder  joint.  This  may  occur  with  or 
without  injury  to  the  brachial  plexus,  and,  as  Turner  Thomas"  has  vigorously 
pointed  out,  it  is  quite  possible  that  the  shoulder  lesion  may  have  been  fre- 
quently overlooked.  If  there  is  a  dislocation  of  the  shoulder  and  it  is  re- 
duced and  the  shoulder  and  arm  are  elevated  and  fixed,  the  patient  is  put 
in  the  most  favorable  position  for  the  healing  of  any  injury  to  the  brachial 


"Ann.   Surg.,   August,   1919,  p.   161. 
'Ann.  .Surg.,  February,   1914. 


154 


OPERATIVE    SURGERY 


plexus  that  may  have  oecurred  at  the  same  time.  Though  many  cases  that 
have  been  called  injury  to  the  brachial  plexus  have  been  chiefly  or  solely 
injuries  to  the  shoulder  joint,  there  is  no  reason  for  denying  the  existence 
of  serious  injury  to  the  brachial  plexus  that  may  cause  paralysis  witliout 
an  accompanying  shoulder  lesion.  Such  lesions  of  the  brachial  plexus  are  not 
infrefiuently  seen  in  adults  as  the  result  of  trauma. 

In  operations  for  this  condition  Sharpe^  advises  a  transverse  incision, 
preferably  in  one  of  the  horizontal  folds  or  creases  of  the  skin  just  above 
and  parallel  to  the  upper  i3art  of  the  clavicle.  In  an  adult  this  incision  would 
hardly  be  satisfactory,  though  it  seems  sufficient  in  an  infant.  In  adults,  the 
incision  should  begin  at  the  upper  portion  of  the  lower  third  of  the  outer 
margin  of  the  sternomastoid  muscle  and  go  outward  and  dowuAvard  to  the 
junction  of  the  outer  and  middle  tliird^j  of  the  clavicle.  The  transverse  incision 
of  Sharpe  for  infants  is  only  about  two  inches  in  length  and  is  made  about 


Fig.    91. — Diagram   of  the  brachial   plexus.      (After 
Gray.) 


Fig.  92. — Injury  of  the  upper  trunk  of  the  brachial 
plexus. 


one-third  of  an  inch  above  the  clavicle.  The  external  jugular  vein  is  doubly 
ligated  and  divided,  the  sternomastoid  and  the  omohyoid  muscles  are  re- 
tracted, and  the  cervical  fascia  which  overlies  the  plexus  is  incised.  The 
transverse  process  of  the  sixth  cervical  vertebra,  the  carotid  tubercle,  is  at 
the  level  of  the  junction  of  the  fifth  and  sixth  nerve  roots  and  serves  as 
an  excellent  guide.  The  nerve  trunks  of  the  brachial  plexus  emerge  from 
beneath  the  scalenus  anticus  muscle.  "While  exposing  the  brachial  plexus 
the  location  and  course  of  the  suprascapular  nerve  should  be  ascertained,  as 
it  is  important  not  to  injure  this  nerve.  After  the  brachial  plexus  has  been 
freed  the  lesion  is  most  frequently  found  in  the  upper  trunks,  that  is  in  the 
fifth,  sixth  and  seventh  cervical,  though  in  breech  presentations  and  in  in- 
juries in  adults,  especially  those  caused  by  the  clavicle,  the  lower  portion 
of  the  brachial  plexus  is  usually  affected.     If  the  nerve  roots  are  completely 


sjour.  Am.   Med.  Assn.,  March   IS,   1916,  p.  SSO. 


REPAIR    OF    NERVES 


155 


torn  their  stumps  are  found  and  sutured  togellier,  lalving  earc  to  remove  all 
the  scar  tissue.     The  teehnic  of  suturin<>'  has  been  described. 

By  elevating  the  slunilder  and  inclining  the  head  and  neck  to  the  af- 
fected side,  a  gap  of  one  ineli  in  the  upper  trunks  of  the  brachial  plexus  can 
be  readily  overcome   (Pigs.  91,  92  and  93). 

If  the  lesion  is  in  the  lower  portion  of  the  plexus  it  may  be  necessary  to 
divide  the  clavicle  and  a  portion  of  it  may  be  resected  permanently  if  it  adds  to 
the  relief  of  the  tension.  If  in  spite  of  posture,  it  is  impossible  to  approximate  the 
ends  of  the  cords  or  trunks  or  if  the  lesion  seems  to  extend  into  the  spinal  column, 


Mple-p)     l.o-iTTai'^e 


Fig.  93. — Excision  of  the  injured  portion  of  the  brachial  plexus.  Insert  (a)  shows  the  sutures 
applied.  The  ends  can  be  approximated  as  the  sutures  are  tied  by  elevating  the  shoulder  and  turning  the 
head  and  neck  to  the  affected  side. 


the  healthy  distal  portion  of  the  brachial  plexus  is  cnt  across  and  the  stump 
sutured  end-to-side  into  the  nearest  cord  after  incising  the  sheath  and  a 
few  nerve  fibers  in  order  to  make  contact  with  the  axons.  Here,  as  in  all 
nerve  surgery,  the  wound  must  be  kept  as  free  of  blood  as  possible.  An 
excellent  posture  for  the  postoperative  treatment  is  to  bring  the  hand  on 
the  affected  side  over  the  head  until  it  touches  the  opposite  ear  and  to 
fasten  the  arm  in  this  position  by  adhesive  and  bandages. 

Some  surgeons,  as  Tubby  and  Hildebrand,  have  endeavored  to  correct 
the  deformity  caused  by  brachial  palsy  by  transplanting  mnscles,  Tubby 
transplanting  a  portion  of  the  triceps  muscle  and  Hildebrand  the  pectoralis 
major.  It  has  been  shown  experimentally  that  if  the  nerve  supply  of  a  muscle 
is  maintained  nninjured  the  muscle  can  be  transplanted  freely  with  but  little 
regard  for  its  blood  supply,  except  that  portion  that  affects  the  nerve.  The 
muscle  will  probably  partially  degenerate,  but  with  its  uninjured  nerve  supply  it 


156  OPERATIVE    SURGERY 

will  regenerate.  Hildebrand's  operation  takes  advantage  of  this  and  maintains 
the  nerve  supply  of  the  major  pectoral  muscle  which  comes  through  the  an- 
terior thoracic  nerves.  He  dissects  free  the  major  pectoral  at  its  origin  and 
turns  up  the  muscle,  suturing  it  to  the  outer  third  of  the  clavicle  and  to  the 
acromion  process,  leaving  its  insertion  and  nerve  supply  intact. 

After  all  operations  for  restoration  of  motor  function  it  is  essential  to 
carry  out  after-treatment  in  which  massage  and  electricity  are  intelligently 
applied  for  a  number  of  months.  Such  treatment  not  only  hastens  regenera- 
tion of  the  nerve  but  keeps  the  muscles  in  a  healthy  condition,  prevents  their 
atrophy  and  renders  them  better  able  to  function  when  the  nerve  regenerates. 

Neurolysis  means  freeing  a  nerve  from  pressure  and  adhesions.  The 
process  is  the  same  as  when  preparing  a  nerve  for  suture  by  dissecting  away 
surrounding  scar  tissue.  Sometimes  the  nerve  fiber  bundles  are  freed  by  longi- 
tudinal incisions  made  in  the  nerve  with  a  fine  sharp  knife.  Precautions  are 
taken  to  prevent  reformation  of  adhesions  as  after  nerve  suturing. 


CHAPTER  XII 
OPERATIONS  ON  BONES 

The  results  of  operations  on  bones  illustrate  very  strikingly  the  great  value  of 
the  application  of  the  knowledge  of  the  biologic  reaction  of  bone  to  infection  and 
to  foreign  substances.  To  plan  intelligently  operations  upon  bones  it  is 
necessary  to  have  in  mind  the  biologic  processes  of  bone  repair.  AVhile  the 
discussion  still  goes  on  as  to  some  of  the  details  of  repair  of  bone,  the  fate 
of  bone  grafts,  and  the  part  played  by  the  periosteum,  there  are  certain 
fundamental  principles  that  are  well  established.  Whether  the  periosteum 
takes  active  part  in  the  reproduction  of  bone,  or,  as  MacEwen  claims,  is 
merely  a  limiting  membrane,  depends  largely  upon  the  definition  of  perios- 
teum. If  the  cambium  layer  on  the  cortex  of  the  bone  is  included  with  the 
periosteum,  it  is  undoubtedly  true  that  this  layer  contains  osteoblasts  and 
will  reproduce  bone.  If  this  layer  is  not  considered  as  a  part  of  the  perios- 
teum proper,  the  periosteum  then  is  only  a  limiting  membrane. 

In  infection  of  the  bone,  however,  which  is  not  too  rapid  many  osteoblasts 
migrate  from  the  bone  and  may  penetrate  all  of  the  layers  of  the  periosteum. 
In  such  instances  even  the  more  superficial  part  of  the  periosteum  may  actively 
participate  in  the  reproduction  of  bone.  When  the  infection  is  very  virulent 
and  overwhelming  or  when  the  nutrient  artery  of  the  bone  is  early  occluded 
by  inflammation,  there  may  not  be  time  for  the  osteoblasts  to  migrate  and 
here  the  periosteum  will  react  in  the  same  manner  as  would  the  periosteum 
over  a  normal  healthy  bone  and  will  only  reproduce  bone  from  the  cambium 
layer.  A  knowledge  of  these  facts  is  particularly  important  in  operating 
upon  osteomyelitis,  because  if  the  infection  is  not  too  virulent  many  osteo- 
blasts may  have  time  to  escape  to  the  periosteum  Avhere  they  Avill  live  be- 
cause of  the  good  blood  supply,  though  practically  all  of  the  shaft  of  the 
bone  may  eventually  be  destroyed  by  the  inflammation.  This  also  explams 
the  development  of  an  involucrum  which  encloses  wdiat  seems  to  be  a  com- 
pletely necrotic  shaft  of  the  bone.  The  reproduction  of  the  shaft  of  a  long 
bone  from  the  periosteum,  is  not  infrequently  seen  and,  as  has  been  pointed 
out  by  Nichols,  if  the  necrosed  shaft  is  removed  at  the  proper  time  when 
the  activity  of  the  periosteum  is  at  its  height,  reproduction  from  the  perios- 
teum is  very  satisfactory.  If,  however,  this  is  attempted  in  a  normal  bone, 
reproduction  of  the  shaft  will  not  take  place  unless  a  thin  layer  of  the  cortex 
or  the  full  cambium  layer  is  permitted  to  adhere  to  the  periosteum. 

In  bone  grafting,  as  in  transplanting  other  tissue,  the  grafts  should  be 
taken  from  the  patient.     It  seems  quite  certain  that  grafts  taken  from  lower 

157 


158  OPKRATIVE    SI'RGERY 

animals  act  only  as  a  foreign  body  and  it  is  doul)tful  wliclhcr  crafts  even  from 
individuals  of  the  same  race  "will  be  satisfactory. 

It  is  best  to  have  the  bone  grafts  in  contact  Avith  other  living  bone,  ])ut 
tliis  is  not  essential,  as  Carter^  shoMs.  Carter  reported  twenty  cases  in  Avliicli 
bone  grafts  were  nsed  to  elevate  the  nose  and  in  many  of  these  cases  the 
grafts  were  not  in  contact  with  the  bone  of  the  face,  but  imbedded  in  soft 
tissue.  Two  to  three  years  after  the  operation  these  transplants  were  still 
in  place  and  some  of  them  larger  than  when  they  were  implanted. 

Wolff's  law  is  important  to  bear  in  mind  when  grafting  bone.  Accord- 
ing to  this  laAv  change  in  the  form,  position  or  function  of  bones  is  followed 
by  definite  changes  in  their  internal  structure  and  also  by  alteration  of  their 
external  conformation  in  accordance  with  mechanical  laws.  The  workings  of 
this  laAv  are  observed  Avhen  a  small  graft  is  inserted  in  the  defect  of  a  large 
bone  and  gradually  develops  to  the  size  of  the  large  bone.  When  a  graft  is 
taken  from  one  tibia  to  fill  a  total  defect  in  the  other  tibia,  it  has  been 
frequently  observed  that  in  the  course  of  time  both  tibias  appear  of  nor- 
mal proportions.  If  the  fibula  is  grafted  to  make  up  the  defect  of  a  tibia  it 
will  hypertrophy  to  the  size  and  general  contour  of  the  tibia.  This  only 
happens,  hoAvever,  if  the  strain  and  stress  to  AAdiich  a  normal  tibia  is  sub- 
jected are  gradually  applied  to  the  graft,  Avhich  seems  to  react  from  the 
stimulus  of  the  giadually  increased  function  of  the  leg. 

In  spite  of  the  similar  construction  of  bone  as  observed  histologically, 
there  is  a  considerable  variation  in  its  function.  Some  bones,  as  those  of 
the  fingers,  receive  quick  and  numerous  though  light  strains.  Others,  as 
those  of  the  leg,  are  capable  of  great  Aveight  bearing  and  of  active  motion. 
Still  others  are  comparatively  fixed  and  merely  serve  to  hold  the  contour  of 
the  soft  tissue  they  support.  It  seems  that  in  grafting  bone  it  is  Avell  to 
consider  its  function.  If  an  active  bone  accustomed  to  motion  and  strain 
is  to  be  repaired  it  Avould  be  Avise  to  take  a  graft  from  a  bone  of  similar 
function.  The  bones  of  the  arm,  for  instance,  could  be  repaired  from  the 
bones  of  the  leg.  For  bones  of  the  face  or  skull,  hoAvever,  Avhose  function 
is  passive,  grafts  may  be  taken  from  bones  of  similar  function  Avhich  Avould 
correspond  to  the  ribs  more  nearly  than  to  the  bones  of  the  leg. 

Whenever  possible  the  periosteum  should  be  attached  to  the  graft.  This 
is  not  only  because  the  layer  of  the  periosteum  next  to  the  bone,  the  cambium, 
is  capable  of  reproducing  bone,  but  because  the  nutrition  of  the  graft  is 
much  better  if  the  periosteum  is  preserved.  McA¥illiams  particularly  has 
called  attention  to  the  fact  that  the  nutrition  of  a  bone  graft  can  be  carried 
on  more  readily  Avhen  the  periosteum  is  preserved  because  anastomosis  of 
the  vessels  in  the  surrounding  soft  tissue  Avith  the  vessels  of  the  bone  occurs 
much  more  ciuickly  and  freely  through  the  medium  of  the  periosteum  than 
Avith  the  bone  graft  Avithout  periosteum.  In  this  latter  instance  bone  salts  must 
be  absorbed  before  definite  connection  AA'ith  the  vessels  of  the  interior  of  the 
bone  can  be  established,  Avhereas  there  is  no  obstacle  to  the  connection  betAveen 

^Med.  Rec.,  New  York,  February   7,   1914. 


BONES  159 

the  vessels  of  sol't  tissue  iiiul  those  of  the  periosUMini.  Tlie  vessels  in  the 
periosttnnu  lun'e  Iheir  iionual  nnatoinie  coininiiniciitioii  Avith  the  vessels  of 
the  hone. 

The  aetion  of  hone  g'rafts  dei)ends  upon  a  numher  of  hiologic  factors. 
In  some  individuals  there  is  an  idiosyneracy  for  the  deposit  of  calcium  and 
hut  little  callus  is  ever  formed,  even  though  the  patient  may  be  otherwise 
healthy.  The  presence  of  syphilis  and  other  diseases  is  supposed  to  interfere 
Avith  the  deposit  of  lime  salts  in  the  callus.  The  free  use  of  irritating  anti- 
septics, the  presence  of  infection,  or  certain  infectious  or  contagious  diseases 
nuiy  interfere  with  the  repair  of  bone  after  a  fracture  or  grafting. 

The  nutrition  of  grafts  and  of  the  bone  to  be  repaired  is  of  great  im- 
portance. Here  as  elsewhere  in  surgical  operations,  the  nutrition  to  the 
parts  affected  should  be  preserved.  Other  things  being  equal,  tissues  with 
the  best  nutrition  repair  most  readily.  The  blood  vessels  to  the  parts  should 
be  respected  and  preserved.  It  is  best  to  do  the  operation  without  a  tourni- 
quet so  that  the  nutrition  of  the  limb  is  not  interfered  with  during  the  oper- 
ation and  because  hemostasis  after  the  operation  is  more  satisfactory  if  the 
wound  is  closed  dry,  Avithout  a  tourniquet  bei]ig  used. 

The  problem  of  nutrition  concerns  not  only  the  supply  of  blood  to  a  part 
but  the  amount  of  tissue  that  has  to  be  nourished.  A  lack  of  consideration  of 
this  feature  may  lead  to  erroneous  conclusions.  The  surface  of  a  solid  body 
varies  as  the  square,  and  the  cubical  contents  as  the  cube  of  its  dimensions, 
so  the  smaller  the  graft  the  greater  is  its  surface  in  proportion  to  its  cubical 
contents  and  the  less  the  burden  of  the  nutrition  to  the  graft.  It  is,  of 
course,  necessary  to  have  a  graft  of  sufficient  size  to  bear  the  strain  that  is 
required  but  this  does  not  mean  that  the  strain  of  the  full  physiologic  func- 
tion of  the  bone  must  be  provided  for  by  the  graft.  Due  consideration  must 
be  given  to  the  hypertrophy  of  the  graft  under  moderately  increased  func- 
tional strain  and  the  smallest  graft  that  will  meet  these  demands  should  be 
selected.  A  i-mall  graft  that  offers  a  small  mass  to  be  maintained  from  the 
nutrition  of  the  local  tissues  will  undergo  more  active  growth  than  a  large 
graft  placed  under  similar  conditions,  which  Avill  add  a  much  greater  burden 
of  nutrition  to  the  surrounding  tissues.  We  know  that  physiologic  function 
is  in  many  instances  altered  to  a  large  extent  by  the  supply  of  nutrition  that 
tissues  receive.  It  is  natural,  then,  to  expect  that  when  a  definite  amount 
of  nutrition  is  divided  among  cells  of  a  large  graft,  osteogenesis  Avill  not  be 
so  rapid  or  so  satisfactory  as  when  the  same  amount  of  nutrition  is  distributed 
to  the  smaller  number  of  cells  in  a  small  graft. 

While  it  is  essential  to  maintain  a  bone  graft  immobilized  much  longer 
than  a  simple  fracture,  gradually  increasing  exercise  or  massage  should  be 
begun  as  soon  as  possible  after  the  period  of  immobilization  has  ceased. 
Grafts  in  the  limbs  should  ahvays  be  kept  immobilized  for  a  minimum  of 
eight  weeks  and  in  the  large  bones,  as  the  femur,  this  period  of  time  should 
be  greatly  extended  before  weight  bearing  is  begun.  Splints  or  braces  should 
ahvavs  be  used  to  take  up  a  part  of  the  strain  on  the  neAAdy  united  graft. 


160  OPERATIVE    f;T'ROERY 

A  knowledge  of  the  reaction  of  bone  to  foreig-n  material  is  essential  to  a  satis- 
factory performance  of  operations  on  bones.  As  has  been  mentioned  in  the  chap- 
ter on  Surgical  Drainage,  bone  tends  to  extrude  irritating  foreign  substances. 
Iron  is  one  of  these  substances.  The  first  reaction  is  absorption  of  the  lime 
salts  in  the  neighborhood  of  the  iron  in  order  to  loosen  Hie  liold  of  the  iron 
on  the  bone.  This  occurs  even  when  there  is  no  infection  ]jut  in  the  presence 
of  infection  this  process  of  absorption  of  the  lime  salts  or  osteoporosis  is  ac- 
centuated. There  are,  too,  diseases  in  which  so  much  demand  is  made  for 
calcium  in  the  body  or  in  which  there  is  such  a  deficiency  of  calcium  that 
the  bones  are  not  properly  supplied  with  this  essential  element.  There  are 
great  variations  in  the  power  of  different  individuals  to  deposit  lime  salts  in  the 
repair  of  bone.  In  some  apparently  healthy  and  vigorous  persons  this  ten- 
dency is  very  slight  while  in  others  and  the  majority  of  healthy  individuals 
there  is  a  marked  tendency  for  a  deposit  of  more  callus  than  appears  to  be 
necessary. 

The  presence  of  iron,  then,  or  any  material  that  is  irritating  to  bone, 
causes  osteopcrcsis  in  its  neighborhood.  Infection  produces  at  first  softening 
of  the  bone  because  dilatation  of  the  vessels  and  local  leukocytosis  cannot 
be  so  readily  accomplished  in  the  rigid  tissues  of  normal  bone  as  in  soft 
tissue,  and  so  nature  tends  to  remove  the  rigid  obstruction. 

"When  an  iron  plate  or  iron  screws  are  used  in  bone  operations  it  has 
been  frequently  noted  by  careful  observers  that  there  is  but  little  if  any 
callus  near  the  iron,  and  if  union  of  the  bone  occurs  it  is  by  callus  formation 
in  that  portion  of  the  bone  most  distant  from  the  site  of  the  iron  screws  or  plates. 
It  seems  a  little  strange,  then,  that  in  repair  of  bone,  which  can  only  be  made  by 
the  deposit  of  calcium  containing  callus,  a  material  is  deliberately  used  which  not 
only  prevents  the  deposit  of  callus  in  its  neighborhood  but  actually  induces  an 
absorption  of  the  lime  salts  that  were  already  there.  In  the  usual  provision  by 
nature  for  much  more  callus  than  is  necessary,  this  handicap  in  the  repair  of  bone 
is  often  overcome  and  sufficient  callus  is  thrown  down  in  the  part  of  the  bone 
distal  from  the  plate  to  make  a  union  that  is  firm  enough  to  remedy  the  weakness 
of  the  bone  at  the  site  of  the  plate.  Occasionally,  too,  the  callus  may  be  so 
abundant  as  to  limit  the  weakening  influence  of  the  metal  to  the  immediate 
layer  of  bone  with  which  it  is  in  contact. 

Bearing  these  facts  in  mind  it  is  easy  to  see  wh}-  the  application  of  metal 
to  bone  is  so  frequently  followed  by  nonunion.  It  is  more  difficult,  however, 
to  understand  why,  when  these  facts  are  known,  metal  plates  are  ever  used. 
Even  if  the  immediate  repair  appears  satisfactory  the  patient  is  never  free 
from  the  danger  of  complications  as  long  as  a  heavy  metal  plate  is  fastened 
to  the  surface  of  the  bone.  Bone  grafts  taken  from  the  same  individual  not  only 
do  not  act  as  a  foreign  irritating  substance,  but  actually  encourage  the  local  os- 
teoblasts to  produce  callus  and  reconstruct  bone. 

In  nonunioiT,  the  graft  and  the  groove  for  its  bed  should  be  made  sufficiently 
long  so  that  the  graft  will  touch  healtliv  bone  at  each  end.    If  it  is  too  short  the 


BONES  161 

exliauslod  and  scliM'osed  bom-  in  llic  innncdiale  i'('<ii()n  of  an  nnnnil(;d  frac- 
ture \vill  not  l)e  able  to  form  a  pcrniancid  union.  If  Ihr  bone  oraflini;,-  is  (b)no 
for  a  fresh  fracture  where  there  is  no  reason  to  suspect  a  deliciency  in  callus 
formation,  tlie  graft  can  be  short  and  merely  extends  into  the  ends  of  the 
fractured  bone  sufficiently  far  to  hold  it  mechanically  in  satisf actor}'  position. 
Here  the  graft  can  be  taken  from  the  ends  of  the  bone  that  is  fractured, 
whereas  in  nonunion  it  is  best  to  take  it  from  a  different  bone  or  at  least  from 
a  region  remote  from  the  fracture. 

Cases  are  occasionally  seen  in  which  there  is  an  unusually  long,  oblique 
or  spiral  fracture  and  in  which  the  temptation  to  encircle  the  bone  with  a 
wire  or  with  metal  bands  is  great,  as  the  mechanical  union  made  in  this  man- 
ner seems  ver^-  satisfactory.  The  same  observations  applying  to  metal  plates 
and  screws,  however,  apply  to  metal  bands  or  wire  that  encircle  the  whole 
bone.  A  weak  area  is  left  where  the  bone  is  encircled,  and  occasionally  there 
is  a  refracture  later  at  this  site.  The  cause  of  this  refracture  is  that  osteo- 
porosis is  established  in  an  effort  to  throw  off  the  irritating  metal.  Oblique 
fractures  of  this  type  most  often  occur  in  the  femur  and  here  the  depth  of  the 
wound  makes  grafting  somewhat  difficult,  and  the  obliquity  of  the  fracture 
increases  this  difficulty. 

Kangaroo  tendon  is  an  excellent  material  to  hold  in  place  a  bone  graft 
or  to  maintain  an  apposition  in  bone  on  which  there  is  but  little  strain.  I 
have  fixed  an  oblique  fracture  of  the  femur  in  a  small  boy  by  encircling  the 
femur  in  several  places  with  stout  kangaroo  tendon,  but  the  constant  strain 
and  cutting  effect  of  the  edges  of  the  bone  on  the  tendon  caused  it  to  give 
way  in  a  few  days.  Here  a  small  margin  of  the  bone,  no  deeper  than  about 
one-third  of  the  diameter  of  the  bone,  can  be  drilled  through  and  a  stout 
metal  wire  applied  in  two  places.  This  does  not  interfere  with  the  broad  sur- 
faces of  the  oblique  fracture  to  prevent  callus  formation  except  within  the 
small  area  within  the  grasp  of  the  wire,  and  it  is  far  preferable  to  encircling 
the  whole  bone  with  a  wire  or  metal  band,  and  gives  as  good  immediate 
mechanical  result. 

No  metal  should  be  used  in  bone  operations  as  a  rule  and  the  instance 
that  I  have  just  cited  is  an  exception  which  only  rarely  occurs.  Even  here 
it  would  be  well  to  have  autogenous  bone  pegs,  to  fix  the  fractured  ends, 
but  as  this  would  considerably  prolong  and  complicate  the  operation  the 
method  described  is  probably  better,  as  it  is  much  shorter  and  simpler. 
As  it  involves  only  a  small  portion  of  the  bone,  the  weakening  should  not 
be  great  enough  to  impair  function. 

A  steel  or  iron  plate  should  have  no  place  in  modern  bone  surgery.  It  not 
only  inhibits  callus  formation  and  causes  osteoporosis  but  is  always  a  poten- 
tial focus  of  infection,  as  it  affords  a  focus  where  bacteria  may  be  deposited 
from  the  blood,  even  if  the  operation  has  been  done  with  every  ritual  that 
is  recommended  by  the  advocates  of  these  plates. 

The  aseptic  technic  of  bone  surgery  should  be  the  same  as  that  of  any 
other  surgerv.    The  difference  is  that  in  handling  bone  with  the  gloved  hands 


162  OPERATIVE    SURGERY 

the  gloves  are  likely  to  be  punctured  and  infection  in  this  way  may  occur 
more  readily  than  in  soft  tissue.  The  operator  should  use  his  common  sense 
in  this  respect  and  handle  the  bone  itself,  particularly  sharp  portions,  with 
heavy  metal  instruments,  but  there  is  no  good  reason  why  he  should  handle 
the  soft  tissues  by  this  teehnic.  Certainly  the  hand  of  a  surgeon  encased 
in  a  sterile  rubber  glove  will  do  less  damage  to  soft  tissues  than  the  crushing 
and  laceration  of  heavy  metal  instruments. 

If  it  has  been  determined  that  a  fracture  should  be  operated  upon,  be- 
cause it  is  a  compound  fracture  or  because  it  is  impossible  to  secure  satisfac- 
tory adjustment  of  the  fragments  without  operation,  or  because  of  nonunion 
or  malunion,  certain  general  principles  should  be  followed  in  the  operation; 
though  there  are  variations  which  are  necessary  in  order  to  meet  the  biologic 
needs  of  the  particular  case.  If,  for  instance,  it  is  deemed  wise  to  operate 
upon  a  fresh  fracture,  all  that  is  needed  is  to  fix  the  fragments  in  a 
mechanical  way  by  bone  grafting  or  suturing  and  by  external  application  of 
splints  or  traction  so  as  to  keep  the  fractured  ends  in  proper  position  during 
the  process  of  repair.  In  malunion  of  fractures  it  is  necessary  to  mobilize 
the  ends,  to  trim  aAva}^  the  callus,  and  to  reduce  the  fragments  as  nearly  as 
possible  to  the  condition  they  were  in  when  the  fracture  was  fresh.  In  non- 
union, an  entirely  different  problem  is  presented.  Here  the  ends  of  the  bone 
are  most  likely  in  contact  or  at  least  in  good  position  but  calcium  salts  have 
not  taken  part  in  the  repair  and  the  union  is  fibrous.  The  main  indication 
is  for  some  procedure  that  will  so  stimulate  the  bone  forming  elements  as 
to  induce  bony  repair. 

In  fresh  fractures  that  are  not  compound  but  in  which  reduction  cannot 
be  accomplished  without  operation,  there  is  a  difference  of  opinion  as  to 
when  operation  should  be  performed.  Some  surgeons  feel  that  it  should  be 
done  immediately  after  receipt  of  the  injury,  others  advise  waiting  until 
the  second  week  after  the  injury,  while  a  number  of  surgeons  take  an  in- 
termediate ground.  Immediate  operation  will  to  some  extent  add  insult 
to  injury,  and  of  necessity  Avill  cause  greater  swelling  and  more  trauma  than 
would  follow  the  nonoperative  treatment  of  the  fracture.  -  On  the  other  hand, 
waiting  until  after  two  weeks  means  repair  has  already  begun,  valuable  time 
has  been  lost,  and  much  of  the  soft  tissue  in  the  neighborhood  has  become 
infiltrated  and  bound  down  by  the  callus.  In  the  first  forty-eight  hours 
after  an  injury  blood  clots  have  formed  and  local  leukocytosis  has  occurred. 
This  means  an  added  immunity  against  infection  and  makes  operation  some- 
what safer  than  if  done  immediately  after  the  fracture.  The  best  time,  then, 
for  operating  on  fresh  fractures  is  probably  between  the  second  and  the 
tenth  day  after  the  injury.  It  is  best  to  operate  without  a  tourniquet,  though 
a  tourniquet  should  be  available  if  unexpected  and  undue  bleeding  is  encoun- 
tered. 

An  incision  in  the  skin  is  made  of  ample  pro]3ortions  so  the  bone  can 
be  reached  without  undue  traction  or  injury  to  the  soft  parts.  The  margins 
of  the  Avound  are  protected  by  towels  fastened  to  the  edges  of  the  incision. 


BONES 


163 


^Vhom>^■^>^  it  is  ])()ssil)li'  In  do  so  i1  is  Ix'st  to  ciii-ry  tlic  incision  down  to  tlie 
bone  throiigli  an  inh'rnmsi'ulai-  s('])tuin  rallici'  tlian  lliroiijih  the  muscle  itself, 
tliouo'li  this  cannot  always  be  done. 

When  the  fracturecl  bone  has  been  fully  exposed  in  a  fresh  fracture 
the  ends  are  reduced  by  manipulation  with  heavy  forceps  or  long  periosteal 
elevators  havino'  considerable  leverage  power.  It  can  then  be  determined 
what  is  the  best  method  of  holding  the  fragments  in  position.  In  some  eases 
an  intramedullary  graft  will  be  sufficient.  This  can  be  secured  from  either 
end  of  the  fracture  l)y  a  chisel  or  a  saw.  A  motor  rotary  saw  is  of  great 
aid  in  this  Avork  and  adds  to  the  accuracy   and  shortens  the  time   of  the 


Fig 


Placing  an    intramedullary    bone   graft. 


-Iloglund's    method    of    placing    an    intra- 
medullary graft. 


operation.  The  periosteum  is  first  peeled  back  and  a  graft  taken  from 
either  end  of  the  bone  about  two  or  three  inches  long.  It  should  contain  the 
full  thickness  of  the  bone.  It  is  not  necessary  to  have  periosteum  with  an 
intramedullary  graft.  The  graft  should  be  sufficiently  thick  to  make  firm 
bony  contact  with  as  much  of  the  interior  of  the  shaft  as  possible,  though 
it  should  not  fit  too  tightly  as  this  may  cause  pressure  necrosis.  Sometimes 
a  fragment  from  a  fracture  may  be  sufficient.  The  medullary  cavity  is 
cleaned  out  with  a  curet  and  a  transplant  two  or  three  inches  long  is  secured 
from  the  most  convenient  end  of  the  bone.  If  a  motor  sa^v  is  used  the  trans- 
plant can  be  cut  beginning  about  an  inch  from  the  end  of  the  bone.  This 
will  leave  an  inch  of  the  circumference  of  the  bone  at  the  point  of  fracture 


164 


OPERATIVE   SURGERY 


intact.  Ill  this  way  more  stability  is  obtained  than  if  the  graft  were 
cut  to  the  end  of  the  fracture.  The  graft  is  fitted,  as  a  rule,  to  the 
distal  end  of  the  fracture  first  and  driven  into  the  medullary  canal 
lightly  for  about  half  of  its  length.  The  distal  end  of  tlie  fractured 
bone  with  the  graft  projecting  from  it  is  placed  at  an  angle  to  the  axis  of 
the  proximal  end  of  the  bone  and  so  manipulated  as  to  introduce  the  graft  into 
the  medullary  canal  of  the  upper  end  of  the  fractured  bone  (Fig.  94).  The 
bone  is  then  swung  into  its  proper  alinement.  The  method  of  Hogiund  can 
often  be  used  if  a  motor  saw  with  parallel  blades  is  employed.  The  graft 
is  taken  from  one  end  of  the  fractured  bone,  beginning  aliout  an  inch  from 
the  end,  and  is  cut  with  parallel  saw  blades  so  the  graft  will  drop  into  the 
medullary  cavity.  It  is  then  driven  down  with  a  punch  through  the  site 
of  the  fracture  and  sufficiently  far  into  the  medullary  cavity  of  the  other  frag- 
ment so  the  fractured  ends  will  be  satisfactorily  immobilized  (Fig.  95).  After 
closing  the  wound,  suitable  splints  or  a  plaster  of  Paris  support  are  applied. 

In  many  instances,  particularly  in  fresh  fractures,  the  intramedullary  graft 


Fig. 


-Albee's  method  of  inlay  bone  grafting. 


may  be  all  that  is  necessary,  but  the  inlay  bone  graft  as  developed  by  Albee-  has 
many  advantages,  particularly  in  nonunion  (Fig.  96).  In  fresh  fractures 
if  there  is  any  reason  to  suspect  that  the  callus  will  not  be  satisfactory 
the  inlay  method  of  Albee  should  be  used.  If  the  inlay  method  is  employed 
the  periosteum  is  not  stripped  back  on  the  fragment  from  which  it  is  pro- 
posed to  take  the  graft,  as  it  is  best  to  have  the  inlay  graft  with  perios- 
teum attached.  The  incision  must  be  generous  and  the  exposure  satisfac- 
tory without  too  strong  retraction.  In  fresh  fractures  the  graft  can  al- 
ways be  taken  from  the  fractured  ends.  The  strength  of  the  graft  should 
be  sufficient  to  keep  the  bone  in  position,  but  it  should  not  be  made  any 
larger  than  to  fill  this  indication,  for,  as  has  already  been  pointed  out,  a 
small  graft  has  more  opportunity  for  nutrition  than  a  large  graft  and  con- 
sequently its  osteogenetic  powers  are  greater. 

In  small  bones,  as  those  of  the  forearm,  it  may  be  necessary  to  secure 
the  graft  from  the  tibia.  By  cutting  an  inlay  graft  much  longer  from  one 
end  of  the  bone  than  the  other,  it  can  be  slid  down  and  made  to  bridge  the 


2Albee,  F.  H.:     Bone  Graft  Surgery,  Philadelphia,  1915,  W.  B.   Saunders  Co. 


BONES 


165 


fracture  willi  alxtiit  two  iiu-lics  of  the  bone  <i,raft  on  eaeli  side.  The  peri- 
osteum and  endosteuni  in  the  grafts  shouhl  not  he  disturbed.  The  graft 
is  held  in  position  by  kangaroo  tendons  which  are  passed  through  drill  holes 
along  the  edge  of  the  groove  in  the  bone,  which  is  the  bed  of  the  graft,  or  the 
piece  of  bone  made  by  cutting  tlu^  short  groove  in  one  end  of  tlie  fragments 
may  be  utilized  in  forming  pegs,  and  these  can  be  driven  into  drill  holes 
that  are  made  along  the  margin  of  the  groove  in  such  a  manner  as  to  hold 
the  graft  snugly  in  position.  The  bone  is  convei'ted  into  these  pegs  by 
a  doweling  instrument,  worked  by  the  motor  of  the  rotary  saw.  Each  peg 
is  from  two  to  three  inches  long  and  will  make  from  two  to  four  fixation 
pegs.  The  doweling  apparatus,  or  motor  lathe,  has  the  same  diameter  as  the 
drill,  so  these  pegs  fit  snugly  and  are  cut  ot¥  by  the  motor  saAv,  leaving 
onl}'  a  short  portion  projecting.     If  there  are  any  fragments   of  bone  left 


Fig.   91. — Inlay   method   of   bone   grafting   of   bones    of   the    forearm. 


they  should  be  preserved  and  just  before  closing  the  wound  placed  around 
the  ends  of  the  fractured  bone  and  about  the  graft  at  this  point.  Such  small 
pieces  of  bone  have  a  large  osteogenetic  power.  In  this  way  no  foreign  sub- 
stance whatever  is  introduced  into  the  bone  but  merely  live  bone  which  will 
serve  to  stimulate  the  local  bone  producing  cells. 

In  small  bones,  such  as  those  of  the  forearm,  the  graft  can  be  held  in 
position  by  kangaroo  tendons  which  encircle  the  bone,  at  least  two  sutures 
being  snugly  tied  over  each  end  of  the  fractured  bone  (Fig.  97). 

In  malunion,  the  first  problem  is  to  reduce  the  fractures  as  nearly  as  pos- 
sible to  the  condition  in  which  they  were  soon  after  the  fracture  occurred. 
The  medullar^'  cavity  in  these  cases  is  found  blocked  with  callus.  It  is  im- 
portant that  this  be  thoroughly  cleaned  out,  not  only  because  it  is  mechani- 
cally more  ditficult  to  unite  the  bone  satisfactorily  when  the  ends  are  solid,  but 
because  a  greater  tax  on  the  local  nutrition  of  tissues  is  made  by  the  solid 
ends  of  the  bone  than  if  they  are  converted  into  cylinders.    The  cj^linder  ends, 


166  OPERATIVE    SURGERY 

too,  are  much  stronger  in  proportion  to  their  "weight  than  the  solid  ends. 
After  a  maluiiion  has  been  properly  prepared  the  teehnic  is  the  same  as  after 
a  fresh  fracture.  If  there  is  much  shortening  it  is  best  to  use  the  inlay  graft 
of  Albee,  Mhich  can  be  so  fixed  as  to  bridge  a  defect  if  much  bone  has  been 
lost,  and  Avill  at  the  same  time  hold  the  fragments  of  bone  in  their  normal 
axial  position.  It  has  been  abundantly  proved  that  a  small  fragment  of 
bone  which  is  made  to  bridge  over  a  defect  between  the  ends  of  the  bone 
will  gradually  hypertrophy  to  the  normal  size  of  the  bone  which  it  unites. 
This  is  the  application  of  AVolff's  law,  but,  of  course,  the  after-treatment 
should  be  so  regulated  as  not  to  place  too  great  a  strain  too  suddenly  upon 
the  graft  before  it  has  had  time  to  become  strong. 

The  problem  of  ununited  fractures  shows  that  something  besides  accurate 
approximation  and  fixation  is  often  necessary  for  the  successful  repair  of 
fractures.  A  considerable  proportion  of  nonunion  of  fractures  occurs  after 
the  application  of  a  steel  plate,  where  the  fragments  are  not  only  brought 
accurately  into  contact  but  are  held  mechanically  immobile  by  the  heavy 
iron  plate  and  screws.  The  reasons  for  nonunion  under  such  conditions 
have  already  been  discussed,  but  they  must  be  borne  in  mind  in  order  to 
take  the  proper  technical  steps  that  will  result  in  a  cure  of  the  nonunion. 

Sometimes  nonunion  may  be  cured  if  the  fibrous  union  is  cut  away,  the 
ends  of  the  bone  freshened,  the  medullary  cavity  reamed  out,  the  ends  of  the 
fractured  bone  made  rough  with  rongeur  forceps,  the  wound  closed  and  the 
proper  splint  applied.  Such  a  procedure  will  cause  bony  union  in  many  un- 
united fractures.  It  is  important  to  ream  out  the  ends  of  the  bone  because  an 
unnecessary  amount  of  solid  bone  structure  is  thus  removed  Avhich  so  takes 
away  an  unnecessary  burden  on  the  nutrition  to  the  bones.  The  ends  of  the 
bone  are  made  rough  by  cutting  small  bites  with  a  rongeur  forceps  because 
in  this  way  greater  leukocytosis  and  more  hyperemia  is  produced.  Fixation 
by  an  external  splint  gives  physiologic  rest. 

The  inlay  graft  method  of  Albee  will  be  followed  more  generally  with 
success  in  nonunion  of  fractures  than  either  the  intramedullary  graft,  or  the 
simple  treatment  which  has  just  been  outlined.  The  inlay  teehnic  differs  some- 
what in  ununited  fractures  because  the  problem  here  is  not  so  much  to  pro- 
duce an  accurate  approximation  as  to  stimulate  osteogenesis.  In  an  un- 
united fracture  the  ends  of  the  bone  are  sclerosed,  there  is  but  little  calcium, 
the  bone  is  soft,  and  the  osteoblasts  have  disappeared  or  degenerated.  This 
process,  as  a  rule,  takes  place  to  a  greater  extent  in  the  distal  fragment  of  the 
fractured  bone 'than  in  the  proximal  fragment  and  it  is  necessary  to  secure  a 
graft  and  to  make  a  bed  for  the  graft  that  will  be  sufficiently  long  for  both 
ends  of  the  bone  graft  to  lie  in  contact  with  healthy  bone  tissue  on  each  side 
of  the  fracture.  In  order  to  get  out  of  the  region  of  the  sclerosed  bone  the 
graft  should  extend  from  two  to  three  inches  from  the  fracture  on  each  end. 
This  means  that  the  length  of  the  graft  must  be  a  minimum  of  four  inches, 
or  better,  it  may  be  five  or  six  inches.     Albee  often  uses  the  same  teehnic  as 


BONES 


167 


in  fresh  fractui'cs.  only  culling'  llic  <:r;it't  aiitl  ^roovf  Avilli  a  luolor  saw  much 
longer  than  he  \voiil(l  in  a  fresh  fracture  l)eeause  of  the  sclerosis. 

If  tlie  <>-raft  is  to  be  taken  from  tlie  fractured  bone  it  should  be  largely 
from  the  proximal  fragment  because  of  the  greater  sclerosis  in  the  distal 
fragment.  If  the  sclerosis  is  extensive,  or  if  the  bones  are  small,  as  in  the  bones 
of  the  forearm,  it  is  best  to  secure  the  graft  from  the  internal  surface  of  the 
tibia.  The  graft  is  fastened  in  position  by  bone  pegs  or  kangaroo  tendons, 
as  has  already  been  described.  The  wound  is  closed  by  suturing  lightly 
the  fascia  and  muscles  and  closing  the  skin  accurately  but  without  ten- 
sion. As  these  cases  are  usually  supported  by  plaster  of  Paris,  it  is  best 
to  use  absorbable  catgut  stitches  in  the  skin  so  that  there  will  be  no  need 
to  remove  the  stitches. 

In  any  repair  of  a  fracture,  whether  it  is  a  fresh  fracture  or  nonunion, 
care  should  be  taken  to  secure  immobilization  and  usually  traction.  Noth- 
ing is  superior  to  properly  applied  plaster  of  Paris.  The  dressing  should  be 
thin  and  the  bony  prominences  should  be  protected  by  extra  padding.     The 


Fig.   98. — A   method   of   extension   that    can   be   used    after    operation    on    the   bones    of   the    arm    or    forearm. 


cast  may  be  snugly  applied  if  the  patient  is  in  a  hospital  where  it  can  be 
promptly  cut  if  there  is  too  much  swelling.  When  in  addition  to  fixation, 
traction  is  necessar^^,  it  can  be  maintained  by  embedding  into  the  plaster  of 
Paris  tAvo  strips  of  wood  that  project  about  six  or  eight  inches  below  the 
lower  part  of  the  foot  or  the  hand.  Before  applying  the  cast,  adhesive  plas- 
ter strips  are  placed  on  the  limb  as  for  a  Buck's  extension.  The  limb  is  well 
padded  below  the  knee  or  the  elbow  and  here  the  plaster  is  loosely  applied  if 
the  fracture  is  above  the  knee  or  the  elboAv,  so  that  the  traction  will  be  ex- 
erted on  the  fracture  itself  and  not  on  the  bony  protuberances  about  the 
joints  distal  to  the  fracture.  A  small  crosspiece  of  wood  connects  the  two 
ends  of  the  strips  that  have  been  embedded  in  the  plaster  of  Paris.  A  rub- 
ber tube  is  passed  through  a  perforation  in  the  ends  of  the  adhesive  plasters 
that  have  been  previously  fastened  on  the  limb.  The  rubber  tube  is  tied  over 
the  cross  strip  of  wood  as  shown  in  the  illustration  (Fig.  98).  In  this  man- 
ner constant  elastic  traction  is  maintained  on  the  limb  without  the  necessity 
of  weights  or  pulleys. 

In  operations  for  fractures  of  the  femur  or  of  the  humerus,  especially  in  mus- 


168 


OPERATIVE    ST'RGERY 


cular  individuals,  some  arrangement  for  traction  is  necessary,  else  the  spasm  of 
muscles  will  be  so  great  as  to  make  undue  pressure  and  strain  on  the  graft. 

Albee's  inlay  method  of  bone  grafting  is  applicable  to  many  fractures 
besides  those  of  the  long  bones.  In  fractures  of  the  patella,  for  instance,  if 
the  excavation  is  cut  with  a  straight  groove  connecting  the  two  fragments  of 
the  patella  and  a  transverse  groove  at  each  end,  a  graft  can  be  so  fashioned 
from  the  tibia  as  to  fit  in  this  groove  and  j^roduce  fixation  of  the  patella. 

In  fractures  or  defects  in  the  lower  jaw  the  inlay  method  maj'  be  utilized 
by  obtaining  a  graft  from  the  tibia  which  may  be  made  to  bridge  over  a  consid- 
erable defect  as  after  partial  resection  of  the  lower  jaw. 


Fig.   99. — Diagram   showing   the    action   of   bone   graft   in    Pott's    disease    of   the   spine. 

Albee  has  secured  very  gratifying  results  by  the  use  of  the  inlay  method 
in  Pott's  disease  of  the  spine  (Fig.  99).  His  technic'^  consists  in  making  a 
sufficiently  long  incision  with  the  patient  prone,  starting  well  above  the 
diseased  area,  going  to  one  side  of  the  midline  and  coming  back  to  the  mid- 
line below  the  diseased  portion.  In  this  way  a  flap  of  skin  is  formed  with  its 
border  well  away  from  the  midline  so  as  to  avoid  pressure  and  to  prevent  the 
skin  wound  coming  directly  over  the  graft.  After  dissecting  up  the  skin  and 
its  subcutaneous  tissue  the  tips  of  the  spinous  processes  and  the  supraspinous 
ligament  are  exposed.  The  supraspinous  ligaments  are  split  with  a  knife  over 
the  tip  of  the  spinous  processes  and  the  intraspinous  ligaments  are  also  split. 


^Albee,  F.  H.:     Bone  Graft   Surgery,   Philadelphia,   1915,   W.  B.   Saunders   Co. 


BONES 


169 


taking  care  to  avoid  tlie  niuselc  or  the  attaclinients  of  muscle  to  the  spinous 
processes.  "Witli  a  broad,  tliin,  sluirp  osteotome  the  spinous  processes  are 
split  from  a   depth  of  one-third  to  two-thirds  of  an  inch,   and  half  of  each 


Fig.   100. — Albee's   method   of  bone   graft   in   Pott's   disease   of  the   spine.      Spinous   processes   have   been    ex- 
posed and  split,  and  a  malleable  probe  is  ready  to  be  placed  in  the  defect. 


Fig.    101. — A  malleable  probe   has  been   forced   into   the   defect   so   as   to   present  an   accurate   shape  and   size 

of  the  graft  to  be  transplanted. 


spinous  process  is  fractured  at  its  base  and  set  open  for  a  sufficient  distance 
to  make  a  groove  large  enough  to  receive  the  graft.  All  of  the  fractured 
halves  of  the  spinous  process  should  be  on  the  same  side.     Bleeding  iDoints 


170 


OPERATIVE    SL'RGERY 


are  tied  or  compressed  with  iiaiize.  The  graft  is  obtained  from  the  internal 
subcutaneous  surface  of  the  tibia.  The  groove  for  the  reception  of  the  graft 
consists  of  the  split  spinous  processes  and  the  cut  supraspinous  and  inter- 
spinous  ligaments  Avith  their  osseous  attachments  undisturbed.  This  leaves 
the  muscles  and  ligaments  intact  save  for  the  split  and  fractured  halves  of 
the  spinous  processes  (Fig.  100).  The  length  and  shape  of  the  graft  is  de- 
termined by  careful  measurement  Avitli  calipers  and  a  flexible  probe,  which 
is  applied  to  the  gutter  bed  (Fig.  101). 

With  the  patient  in  the  same  prone  position  the  leg  from  Avhich  the  graft  is 
to  be  taken  is  flexed  to  an  acute  angle  on  the  thigh  and  an  incision  is  made  along 
the  inner  border  of  the  inner  surface  of  the  tibia.  It  should  be  so  placed  that  the 
skin  incision  will. not  lie  directly  over  that  portion  of  the  bone  from  which  the 
graft  is  taken.  The  skin  is  dissected  from  the  periosteum  and  the  pattern  of  the 
graft  is  outlined  on  the  periosteum  by  placing  the  molded  probe  on  the  periosteum 
and  cutting  the  outline  of  the  graft  on  the  periosteum  along  the  margins  of  the 
probe,  just  as  a  tailor  cuts  the  cloth  by  laying  the  pattern  on  it  and  cutting  along 


Fig.   102. 


-The  bone  graft  has  been  cut,  molded,  and  placed  in  position  between  the  split  spinous  processes. 
It   is   being   sutured   in   position   with   interrupted   sutures    of   kangaroo    tendon. 


the  edges  of  the  pattern.  If  the  graft  is  to  be  curved  the  two  ends  should  lie 
posterior,  so  that  the  apex  of  the  curve  is  at  the  crest  of  the  tibia,  which  is 
the  strongest  part.  A  straight  graft  is  obtained  by  cutting  the  cortex  of  the 
tibia  through  to  the  marrow  cavity  with  a  motor  circular  saw  along  the  in- 
cisions in  the  periosteum  that  have  already  been  made.  A  curved  graft  can 
be  cut  in  a  similar  manner,  using  the  motor  saw.  A  molded  graft  is  made 
by  sawing,  at  regular  intervals,  partly  through  the  surface  of  a  straight  graft 
and  then  bending  the  graft  into  the  proper  curve.  This  is  best  done  by  the 
motor  saw,  which  has  a  guard  so  set  that  it  will  cut  a  definite  depth  and  no 
deeper.  The  ends  of  the  graft  may  be  loosened  by  saw  cuts  made  by  a  very 
small  motor  saw  or  by  a  thin  osteotome.  The  graft  is  removed  by  prizing 
it  up  with  a  thin  osteotome,  taking  care  to  jireserve  the  attachment  of  the 
periosteum.  A  graft  can  be  made  with  a  chisel  or  hand  saw,  but  the  motor 
saw  is  far  preferable.  After  removing  the  graft  it  is  immediately  transferred 
to  its  gutter  bed  and  is  held  in  place  by  strong  kangaroo  tendon  sutures 
through  the  split  halves  of  the  supraspinous  ligament  (Fig.  102).  The  suture 
should  be   so    adjusted   as   to   secure    a   firm    grasp    on   the   ligaments    and   to 


BONES  171 

keei)  the  g'raft  lii-iuly  in  iiositiou.  At  the  points  of  fixation  at  the  ends  of 
the  graft,  sharp  (.-orners  are  removed  by  rongeur  foreeps  and  these  cliips  are 
placed  around  the  ends  of  the  graft  where  it  is  in  contact  with  the  spin- 
ous process,  before  tying  the  sutures.  Kangaroo  tendon  sutures  are  placed 
at  intervals  of  about  half  an  inch.  If  the  graft  is  a  curved  one  and  not 
molded,  the  periosteum  should  lie  on  one  side  next  to  the  spinous  proc- 
ess and  the  endosteum  on  the  other.  The  skin  is  closed  in  the  usual  way 
and  sterile  dressings  are  applied.  It  is  important  to  prevent  pressure  on  the 
graft,  particularly  if  there  is  a  marked  kyphosis. 

Albee's  method  of  inlay  grafts  for  Pott's  disease  of  the  spine  is  largely 
founded  on  the  fact  that  the  spine  is  made  up  of  a  series  of  levers,  each 
vertebra  being  an  individual  lever  with  its  fulcrum  at  the  lateral  facets.  The 
anterior  arm  of  the  lever  is  the  body  of  the  vertebra  and  the  posterior  arm  is 
the  spinous  process.  In  destruction  of  the  vertebral  body  that  portion  tends 
to  collapse,  but  by  fixing  the  spinous  processes  at  their  extremities  the  strain 
of  the  pressure  on  the  diseased  body  of  the  vertebra  is  taken  up  by  the  poste- 
rior end  of  the  lever  and  the  parts  are  put  at  rest  (Fig.  99). 

In  the  postoperative  treatment  the  patient  is  placed  on  a  fracture  bed  for 
five  or  six  weeks  with  no  other  restraint  than  a  towel  across  the  chest,  which 
is  fastened  to  four  strips  of  a  broad  muslin  band,  tied  at  each  corner  of  the 
bed.  If  there  is  marked  kyphosis  abundant  pads  must  be  placed  on  each 
side  to  take  up  the  pressure.  No  external  fixation  is  applied  to  the  spine  dur- 
ing the  convalescence  except  in  unusual  cases,  where  a  light  brace  or  plaster 
of  Paris  support  may  be  worn  for  five  or  six  weeks. 


CHAPTER  XIII 
PLASTIC  SURGERY 

Plastic  surgery  is  that  branch  of  surgerj'  which  is  concerned  with  correct- 
ing defects  that  result  from  trauma,  disease,  or  errors  of  development.  While 
in  a  broad  sense  it  may  be  applied  to  operations  on  any  kind  of  tissue,  as 
bones,  tendons  or  nerves,  affected  by  trauma  or  disease,  it  is  usually  em- 
ployed in  reference  to  correction  of  defects  involving  the  skin  or  mucosa 
either  entirely  or  in  a  large  part.  Plastic  surgery  is  chiefly  concerned  with 
the  face  though,  of  course,  any  portion  of  the  body  in  which  there  are 
defects  from  injury  or  disease  or  from  errors  of  development  may  be  the 
subject  of  plastic  operations. 

The  principles  of  plastic  operations  are  concerned,  first  of  all,  Avith  the 
nutrition  of  the  corrected  tissue,  and,  secondly,  with  a  mechanical  reconstruc- 
tion that  will  bring  the  j)arts  as  nearly  as  possible  to  a  normal  condition. 
Operations  that  apply  to  particular  regions  will  be  discussed  in  the  chapters 
devoted  to  regional  surgery,  but  there  are  many  underlying  principles  that 
must  be  borne  in  mind  if  success  is  desired  in  this  branch  of  surgery,  no 
matter  in  what  portion  of  the  body  it  is  applied. 

Plastic  operations  are  of  two  types :  that  in  which  the  margins  of  the 
wound  are  prepared  for  a  fresh  union  and  sutured  without  transplanting 
tissue  or  Avithout  the  intervention  of  flaps,  and  that  type  in  which  flaps 
or  grafts,  free  or  pedunculated,  are  necessary.  The  former  type  is  appli- 
cable in  harelip  and  cleft  palate  or  in  defects  that  follow  a  small  or  nar- 
row injury.  Usually  after  burns  or  extensive  traumas  the  resulting  de- 
formity is  so  great  that  it  is  impossible  to  reconstruct  the  tissues  by  excision  of 
the  affected  part  and  union  of  the  edges  of  the  wound.  In  such  cases  several 
procedures  are  open.  One  is  to  undermine  the  margins  of  the  wound  for  a  con- 
siderable distance  and  determine  if  the  additional  elasticity  obtained  l)y  the 
undermining  will  permit  approximation  of  the  edges  of  the  wound.  If  this  is 
impossible  the  raw  surface  can  at  least  be  diminished  by  sutures  at  the  cor- 
ners or  angles  of  the  raw  surface. 

Davis^  has  secured  excellent  results  by  gradual  excision  of  the  scar  tissue. 
If  a  scar  is  too  broad  for  total  excision  and  approximation  of  the  edges  of  the 
wound,  an  oval  area  is  excised  from  the  center  of  the  scar  and  the  edges 
of  the  wound  are  approximated.  After  this  has  healed  firmly,  which  is  from 
a  few  weeks  to  two  months,  another  mass  of  the  scar  tissue  is  excised.  In  this 
way  the  elasticity  of  the  skin  will  permit  approximation  of  the  healthy  j^ortion 
of  the  skin  by  gradual  traction  Avhicli  would  be  impossible  if  all  of  the  scar  tis- 


iDavis,  J.   S.:     Plastic   Surgery,   Philadelphia,   1919,   P.   Blakiston's  Son  &  Co.,   p.   212. 

172 


PLASTIC    SURGERY  173 

sue  wore  excised  at  oiiee.  Often,  liowever,  even  this  will  not  suffice,  for  tlie  de- 
fect or  deformity  is  too  great,  lu  sucli  cases,  flaj)s  or  grafting  must  be  re- 
sorted to. 

The  operation  to  be  performed  depends  largely  upon  the  part  of  the  body 
affected  and  also  upon  the  function  of  this  region.  If,  for  instance,  there  is 
a  large  raw  surface  on  the  back  of  the  legs  where  a  scar  will  not  be  conspicuous 
or  annoying,  the  chief  indication  is  to  heal'the  raw  surface  even  if  there  results 
a  marked  scar.  It  is  always  desirable  to  have  as  little  scar  tissue  and  as  nearly 
a  normal  skin  as  possible,  but  if  a  large  defect  on  the  body  or  limbs  can  be  so 
healed  as  to  give  the  patient  no  discomfort  and  not  to  interfere  with  function, 
the  main  indication  will  have  been  fulfilled  and  it  will  hardly  be  justifiable 
to  undertake  prolonged  and  complicated  operations  to  render  the  scar  less 
jirominent  when  a  simple  procedure  will  fill  every  other  indication. 

Plastic  surgery  chiefly  concerns  the  face  and  the  hands.  Methods  that  not 
only  restore  function  but  remove  deformity  completely  are  chiefly  desira- 
ble. Flaps  of  living  whole  skin  Avith  a  pedicle  usually  give  the  best  re- 
sults from  every  standpoint.  They  should  be  matched  with  the  texture  of 
the  skin  around  the  defect  as  far  as  possible.  As  a  rule,  flaps  taken  from 
the  margins  of  the  deformity  come  nearer  to  corresponding  with  the  texture 
of  the  skin  in  the  region  of  the  defect  than  flaps  taken  from  some  distant 
part.  Esser^  has  called  particular  attention  to  this  feature.  Sometimes,  hoAv- 
ever,  it  is  impossible  to  obtain  flaps  at  the  defect  and  they  have  to  be  trans- 
planted from  a  distance  and  the  pedicle  cut  .after  the  flap  has  been  in  position 
a  sufficient  length  of  time  to  obtain  its  nutrition  locally. 

A  flap  of  the  wdiole  skin  with  a  pedicle  can  often  be  obtained  from  the 
region  of  the  defect  with  a  view  to  remaining  permanently  in  position. 
The  flap  should  be  so  shaped  that  the  pedicle  will  form  part  of  the  reconstructed 
field.  A  flap  may  also  be  obtained  from  distant  portions,  as  from  the  arm, 
and  allowed  to  remain  in  position  for  about  two  weeks.  The  pedicle  is  then  cut. 
A  free  transplant  of  whole  skin  may  be  used  if  the  defect  is  not  too  large. 
The  wdiole  skin  method  is  called  the  Wolfe-Krause  method.  Wolfe  insisted 
upon  the  removal  of  the  subcutaneous  fat.  The  subcutaneous  fat  in  a  trans- 
plant of  wdiole  free  skin  is  of  no  advantage  but  probably  an  additional  bur- 
den.   J.  S.  Davis,  of  Baltimore,  has  developed  this  method  quite  extensively. 

When  the  appearance  of  the  scar  is  of  secondary  importance  and  the 
healing  of  the  wound  is  the  main  object,  thin  grafts  of  epidermis,  the  so-called 
Thiersch  grafts,  are  very  satisfactory.  When  properly  applied  on  a  clean 
field  such  grafts  usually  take  wdthout  trouble  and  large  raAV  surfaces  that 
would  require  months  to  heal  or  would  probably  never  heal  are  closed  in  ten 
days  or  tW'O  weeks. 

Thiersch  grafts  would  be  universally  used  instead  of  free  transplants 
of  whole  skin  or  flaps  except  for  two  disadvantages;  the  scar  resulting  is 
conspicuous,  for  the  skin  of  the  scar  does  not  appear  to  be  normal,  and  there 


2Surg.,  Gynec.  &  Obst.,  June,  1917,  pp.  737-748. 


174  OPERATIVE    SURGERY 

is  often  a  marked  tendency  to  contraction  after  tlie  nse  of  Thiersch  grafts. 
This  is  partienlarly  true  if  applied  after  a  burn,  and  the  reason  is  that 
in  the  Tliiersch  grafts  nothing  but  the  epidermis  or  the  epithelial  elements 
are  used.  The  contraction  after  an  injury  to  the  skin  of  the  face,  for 
instance,  is  not  in  the  epithelial  elements  of  the  skin  but  in  the  connec- 
tive tissue  that  underlies  the  epithelium.  In  other  words,  the  contraction 
lies  in  Avhat  corresponds  to  the  corium,  which  is  composed  largely  of  con- 
nective tissue  and  on  Mhich  rests  the  epithelial  layer.  If,  in  the  healing  proc- 
ess, this  is  made  up  of  scar  tissue,  particularly  of  the  dense  scar  tissue 
that  follows  a  burn,  contraction  deformity  will  probably  result  even  though 
the  surface  may  be  covered  by  healthy  epithelium.  It  is  contraction  in  this 
subepithelial  layer  that  produces  the  striking  deformities  following  burns  of 
the  face  or  hands  Avith  the  eversion  and  twisting  of  the  features,  while  con- 
traction in  the  submucous  layer  causes  the  strictures  of  the  urethra  that  fol- 
low ulceration.  In  all  of  these  instances,  the  contraction  is  due  not  to  the 
epithelial  elements,  which  may  be  perfectly  healthy,  but  to  the  connective 
tissue  elements  on  which  the  epithelium  rests. 

If,  then,  a  scar  contraction  is  excised  and  Thiersch  grafts  are  used  to  heal 
over  the  surface,  the  scar  contraction  will  almost  invariably  recur  beneath 
the  Thiersch  graft.  In  order  to  avoid  this  it  is  necessary  to  use  the  whole 
skin  which  contains  not  only  the  epidermis  but  normal  healthy  corium  that 
does  not  contract. 

Often  incisions  may  be  so  made  or  flaps  so  shaped  as  to  secure  tissue 
from  the  neighborhood,  which  at  first  sight  might  seem  impossible.  Due  re- 
gard must  always  be  had  for  nutrition  of  flaps,  and  the  pedicle  should  pref- 
erably be  located  in  the  general  direction  of  the  blood  supply  of  the  skin  of 
which  the  pedicle  is  formed.  The  flaps  should  be  handled  as  little  as  pos- 
sible and  as  gently  as  possible.  It  must  be  borne  in  mind  that  unnecessary 
trauma  not  only  destroys  in  a  flap  living  tissue  that  might  serve,  but  adds 
an  extra  burden  to  the  blood  supply  which  must  absorb  the  injured  cells  and 
bring  nutrition  for  repair  of  the  defect  left  by  their  removal.  In  very  vas- 
cular regions,  such  as  the  face,  it  is  often  possible  to  disregard  the  direction 
of  the  blood  supply  in  making  a  flap  because  the  blood  supply  is  so  abundant 
here  and  the  collateral  circulation  is  so  great  that  a  flap  may  be  sufficiently 
nourished  if  the  pedicle  is  large  enough,  even  though  the  blood  must  come 
from  the  opposite  direction  of  the  normal  blood  supply. 

Besides  handling  the  flap  gently  and  providing  sufficient  nutrition  through 
its  pedicle,  care  must  be  taken  to  insert  the  sutures  in  such  a  manner  that 
too  much  tension  will  not  be  made.  No  matter  how  carefully  the  pedicle  may 
be  handled  or  shaped,  if  it  is  sutured  so  that  there  is  too  great  tension,  the  blood 
supply  will  be  obstructed  and  the  flap  will  be  partially  or  totally  destroyed. 
Occasionally  when  tension  in  a  flap  is  unavoidable,  it  is  best  to  concentrate 
it  upon  one  or  two  tension  sutures  that  w^ill  produce  pressure  only  in  one 
place  and  relax  the  rest  of  the  flap  so  there  will  be  enough  nutrition  along 
the  margins  for  satisfactory  union.     The  nutrition  of  a  flap  may  also  be  im- 


PIvASTIC    SUROKRY  175 

jii'I'iKmI  l»y  \(Mi()\is  stasis.  C.  11.  JNlayo  lias  ol'lcii  ciiipliasizcd  iliis  j)()iii1. 
Not  infreqiUMitly  llie  blood  supply  to  a  llap  would  he  sufficient  except  tluit 
the  venous  return  is  imperfect  and  this  blocdvs  the  capillaries  which  in  turn 
prevent  the  feeble  arterial  current  from  being  effective.  In  one  instance 
in  Avhich  1  1rans[)lan1ed  a  Ihi])  from  the  forehead,  preserving  the  temporal 
artery,  the  arterial  nutrition  of  the  flap  was  abundant,  hut  gangrene  of  a 
large  portion  of  it  occurred  because  the  venous  return  Avas  not  sufficient. 
Whei-ever  a  large  flap  with  a  narrow  pedicle  is  transplanted  this  condition 
nuiy  obtain  and  should  be  carefully  avoided.  This  is  done  by  several  short 
stab  wounds  in  the  substance  of  the  flap  and  by  leaving  small  gaps  be- 
tween the  stitches  along  its  margin  through  Avhich  the  venous  blood  is  emp- 
tied, so  relieving  the  passive  hyperemia. 

Many  of  the  procedures  used  to  close  defects  have  become  almost  classical. 
The  chief  methods  are  given  in  the  accompanying  illustrations,  which  are 
self-explanatory  (Figs.  103,  104  and  105).  The  methods  of  Szymanowski  are 
ingenious  and  usually  satisfactory  (Fig.  106).  Often  a  simple  relaxation  in- 
cision parallel  with  the  wound  will  be  all  that  is  necessary.  An  oval  defect 
can  be  closed  by  any  one  of  a  number  of  different  procedures.  Lisfranc's 
method  is  simple  and  useful.  In  many  instances  the  sliding  of  flaps  not  in- 
frequently causes  puckering,  which  is  often  conspicuous.  This  is  eliminated 
wdienever  possible  either  by  suturing  or  l}y  incision  of  a  triangular  area  that 
includes  the  puckered  portion  (Figs.  107  and  108).  Oval,  circular  or  quad- 
rangular defects  may  be  closed  as  shown  in  the  illustrations  (Figs.  109,  110, 
111,  112,  113,  114,  115,  116,  117,  118,  119,  120,  121,  122  and  123). 

If  the  flap  cannot  be  carried  to  the  affected  part,  which  is  done  in  defects 
about  the  face,  the  affected  part  can  sometimes  be  carried  to  the  flap,  as  Avhen 
plastic  operations  are  performed  on  the  hands  or  on  the  loAver  extremities. 
Defects  about  the  hand,  forearm,  or  elbow,  may  be  repaired  by  a  flap  from  the 
abdomen,  which  is  dissected  up  as  a  bridge  of  tissue  between  two  parallel 
incisions  and  is  left  attached  at  each  end.  The  defect  on  the  hand  is  pre- 
pared for  a  graft  and  the  hand  is  inserted  under  the  bridge  and  the  edges  of 
the  skin  of  the  bridge  of  tissue  are  united  to  the  margins  of  the  wound  on  the 
hand  by  sutures.  After  about  tAvo  weeks  the  flap  is  cut  away.  By  making  a 
flap  with  its  broad  base  from  the  upper  part  of  the  abdomen  the  whole  por- 
tion of  the  flap  except  its  base  can  be  sutured  to  the  defect.  In  this 
Avay  lesions  of  the  palm  of  the  hand  are  satisfactorily  repaired  and  the  pa- 
tient is  much  more  comfortable  than  Avhen  the  hand  is  carried  to  the  back. 

When  a  pedicle  must  be  cut,  it  is  necessary  to  see  that  the  flap  is  suffl- 
ciently  nourished  by  its  ncAV  location  before  severing  the  pedicle.  When  the 
pedicle  is  flrst  severed  the  flap  ahvays  becomes  somcAvhat  paler,  but  if  the  pa- 
tient is  young  and  in  good  health  and  the  flap  in  good  condition,  a  pedicle 
can  usually  be  safely  cut  at  the  end  of  twelve  days  or  two  weeks.  If  in  doubt, 
it  is  advisable  to  compress  the  pedicle  Avith  a  soft  clamp  for  an  hour  a  day 
for  several  days  before  cutting  it.  In  this  AA^ay  collateral  circulation  is 
deA'eloped. 


176 


OPERATIVE   SURGERY 


'S 


Fig.    103. — ClosLire    ot    a   triangular   defect   by   the 
method  of  Jasche. 


/     / 


Fig.    104. — Clos '.re    of    a    triangular    defect    by    the 
method    of    Szymonowski. 


\/\^        - 


Fig.    1C5.— Closure    of    -j.    triangular    defect    by    the 
method   of   Amnion. 


\ ^  n,M  f 1 


Fig.    106. — Closure    of    a    triangular    defect    by    the 
second   method    of   Szymonowski. 


Fie      106-^.— Third    method    of    closure    of    trian- 
.  gular   defect  according  to    Szymonowski. 


,  .fijo 


Fig.    107. — Closure    of   a   triangular    defect    by    the 
method  of  Burow. 


jficr.   108. Second   method   of  closure  of  triangular   defect  according   to   Bur 


4-5- 


Fig.    109. — Closure    of    oval    defect    by    method    of 
Lisfranc. 


u 


)^ 


Fig.    110. — Closure    of    oval    defect    by    method    of 
Szymonowski. 


Fig.    111. — Closure    of    oval    defect    by    method    of 
Celsus. 


\  -U' 


Fig.    112.— Closure    of    oval    defect    by    method    of 
Dieffenbach. 


PLASTIC    SURGERY 


177 


W  J 


Fig.    113. — Closure    of    oval    defect    by    double    flap 
method. 


Fig.    114. — Closure    of    oval    defect    by    method    of 
Weber. 


T    f   r  r  r.*  T  r   r  f   r  r 


Fig.  115. — Closure  of  circular  defect  by  first  method  of  Szymonowski. 


•  T  r  w  T  r  r  n 


Fig.    116. — Closure   of   circular   defect   by   second   method    of    Szymonovi'ski. 


r  r  r  r 


r  r  r  T. 


r  r  r  r 


\  V  r  r 


Fig.    117. — Closure    of   circular    defect    by    third    method    of    Szymonowski. 


■<;  r  V  r  r  r 


\\  \  \  ■k  K 


Fig.    lis. — Closure    of  quadrilateral    defect    by 
method    of    Cole. 


Fig.    119. — Closure   of   quadrilateral   defect   by   first 
method  of   Szymonowski. 


f  r   lUi^r  .w  r 


1"    \ 


Fig.    120. — Closure    of   quadrilateral   defect   by    sec- 
ond method  of  Szymonowski. 


t  T  t  t  f  r 


f  f  t  f  f  t- 


Fig.    121. — Closure    of    quadrilateral    defect    by 
method    of    Dieflfenbach. 


-5-M- 


4-W- 


-i-i-!- 


-T  r  r- 


X 


\\  \  \  ■\  \  ^\ 


^ 


1°  r  t   ij — <— ;- 


"\, 


Fig.    122. — Closure    of    quadrilateral    defect   by 
method   of   L,exer-Bevan. 


Fig.    123. — Closure    of    quadrilateral    defect    by 
method  of  Burow. 


178 


OPERATIVE    SURGERY 


If  it  is  desired  to  transfer  a  long  narrow  (la])  from  the  neck  to  a  region 
on  the  face  it  is  often  too  risky  to  imperil  the  nutrition  liy  doing  the  opera- 
tion in  one  stage.  Tiie  nutrition  from  the  pedicle  of  the  flap,  however,  can 
be  improved  by  first  outlining  the  fhi]i  l)y  incisions  and  then  the  l)ridge  of  tis- 
sue for  the  pedicle  is  undermined  and  sepai'ated  by  ruliber  tissue  or  some  imper- 
vious dressing  from  the  underlying  raw  surface.  In  this  manner  the  nutri- 
tion at  the  tAvo  ends  of  the  flap  will  be  developed.  The  end  that  is  to  l)e 
severed  is  divided  in  sections  at  intervals  of  several  days  so  that  all  of  the 
nutrition  will  be  gradually  developed  from  that  end  of  the  flap  which  is  to  be 
the  pedicle. 

One  of  the  most  interesting  and  valuable  principles  in  plastic  surgery  is 


Fig.  124-A. — "Tubed"  iiedicle  flaij.  Tht-  iialieiit,  a  young  boy,  bad  a  severe  defect  following  noma, 
which  resulted  in  the  sloughing  away  of  the  cheek  and  a  large  portion  of  the  superior  maxilla.  There  was 
complete  bony  ankylosis  of  the  lower  jaw  and  he  was  fed  through. the  defect.  The  illustration  is  a  photo- 
graph which  shows  the  defect  and  the  "tubed"  pedicle  flap  which  was  gradually  dissected  free  at  intervals 
of  several   days,   so   developing  a   blood   supply   in   the   pedicle. 

the  development  of  the  blood  supply  from  a  comparatively  small  pedicle.  In 
extensive  reconstruction  work  about  the  face  this  is  essential  for  success. 
"Tubing"  of  the  pedicle,  introduced  by  H.  D.  Gillies,"  is  a  valuable  aid  in 
carrying  out  this  principle.  A  flap  is  outlined  from  the  chest  and  lower 
part  of  the  neck  of  such  a  size  and  shape  as  may  be  best  suited"  to  the  facial 
defect.  The  pedicle  extends  from  just  beloAv  the  angle  of  the  jaw  to  the  main 
body  of  the  proposed  flap.     It  is  about  one  and  a  half  or  tAvo  inches  broad 


='Surg.,  Gynec.  &  Obst.,  February  20,   1920,  pp.  121-134. 


J'LASTIC    SrUdKHV 


17i) 


and  is  raised  nwv  an  cxlcnl  of  I'onr  indies  oi'  lon.-i'er,  depending'  upon 
the  loealion  lo  wliirli  Hie  Hap  ninst  be  1  ranst'erred.  After  dissecting  the  ped- 
icle  from  its  base  P.  Ihe  margins  of  the  pro))osed  flap,  II10  edges  of  tlic  skin  of 
tlie  ])edieh>  are  sninred  together  with  a  eontinuoiis  sntnre.  In  lliis  way  the 
raw  snrfaee  of  th(>  pediele  is  free  from  infection  and  also  from  the  trauma 
and  h)ss  of  bb)od  wliieh  an  exposed  granulating  surface  is  likely  to  undergo. 
The  margins  of  the  wound  from  wdiieh  the  pedicle  has  been  dissected  are 
undermined  and  united  beneath  the  tubed  pedicle  so  there  is  a  mininuim  of 
raw  surface  exposed.  About  a  week  later  one-third  of  the  flap  is  dissected  from 
its  bed  (Figs.  124  A,  B,  and  C,  and  125) .  If  the  flap  is  to  cover  part  of  the  cavity 
of  the  mouth  its  raw  surface  is  grafted  with  Thiersch  grafts,  or  two  flaps  may 
be  developed  with  tubed  pedicles  and  one  turned  with  the  epithelial  surface 
within   the   mouth   and   the    other   with   the   skin   external.      At    intervals    of 


r 

p*^ 

■ 

"^     1 

«• 

1 

K%^ 

''^^.- 

Fig.  124-B. — Photograph  of  the  patient  shown 
in  the  preceding  illustration  three  months  later. 
The  flap  from  the  neck  had  been  turned  wi'h  the 
skin  side  inward  and  the  flap  from  the  forehead 
with  the  skin  side  outward.  The  pedicles  were 
severed  after  clamping  the  pedicles  with  soft  for- 
ceps   for   half   an   hour   a   day   for   about   ten   days. 


Fig.  124-C. — Photograph  of  the  patient  shown 
in  the  two  preceding  illustrations.  This  photo- 
graph was  taken  about  seven  months  after  that 
shown  in  Fig.  124-B.  The  ankylosis  was  overcome 
by  the  Esmarch  operation  and  the  Hp  was  repaired 
by  using  the  mucosa  that  extended  on  the  left  side 
up  to  the  nose,  the  technic  being  similar  to  that 
of  the  Owen  operation  for  harelip.  The  photo- 
graph shows  the  extent  to  which  the  mouth  can  be 
opened. 


about  a  Aveek  the  flap  is  again  dissected  in  three  stages  covering  a  period  of 
three  or  four  Aveeks  until  it  is  entirely  divided.  This  wdll  develop  a  lilood 
supply  through  the  pedicle  so  the  flap  can  be  transferred  without  fear 
of  insufficient  nutrition.  Sometimes,  as  recommended  by  Gillies,  a  large  flap 
to  cover  an  extensive  defect  of  the  face  can  be  raised  from  the  front  and  up- 
per part  of  the  chest  by  having  tw-o  tubed  pedicles,  one  on  each  side  of  the 
neck.     AVhen   the   pedicle   is   to   be    severed    it   can   be    cither    gradually   cut, 


180 


OPERATIVE    SURGERY 


severing  about  one-third  at  a  time,  at  intervals  of  a  week,  or  it  may  be 
compressed  with  a  soft  clamp  or  a  rubber  band  for  an  hour  twice  a  day  for 
a  Aveek  before  being  severed.  In  this  way  the  blood  supply  is  gradually  thrown 
upon  the  new  attachments  of  the  flap  in  such  a  manner  that  the  local  nutrition 
is  surely  established,  whereas  a  complete  severing  of  the  pedicle  without  pre- 
liminary preparation  might  result  in  such  poor  nutrition  that  the  flap  would 
break  down  (Fig.  126). 

These  principles  of  gradual  development  of  the  blood  supply  of  a  flap 
are  exceedingly  important  in  repairing  an  extensive  defect  and  will  enable 
deformities  to  be  corrected  much  more  satisfactorily  than  by  the  old  method 
of  a  two  stage  operation  in  which  the  flap  is  completely  dissected  at  one  stage 
and  the  pedicle  severed  at  another. 


Fig.  125. — "Tubed"  pedicle  which  has  been 
Thiersch  grafted  on  the  raw  surface  and  is  ready 
to  be  turned  into  the  defect  in  the  face. 


Fig.  126. — The  flap  with  the  tubed  pedicle 
shown  in  Fig.  125  has  been  sutured  into  the  de- 
fect in  the  face.  A  soft-nosed  clamp  is  placed  on 
the  pedicle  at  intervals  to  develop  blood  supply  to 
the  flap. 


''Jumping"  and  "waltzing"  flaps  may  sometimes  be  resorted  to.  A  flap 
may  be  turned,  for  instance,  to  the  margins  of  the  wound  and  kept  there  un- 
til the  nutrition  is  well  established.  Then  its  pedicle  is  cut  and  turned  over 
the  defect;  or  a  flap  from  the  abdomen  may  be  sutured  into  a  wound 
made  on  the  hand  for  its  reception  and,  after  it  has  taken,  the  pedicle  to  the 
abdomen  is  cut  and  the  hand  with  the  transplanted  flap  carried  to  the  face. 
The  flap  is  sutured  into  its  new  position,  the  pedicle  to  the  hand  being  severed 
at  the  proper  time. 


PLASTIC    SURGERY  181 

Transplantation  of  whole  skin  is  always  desirable  because  of  the  better 
scar  that  results  and  the  absence  of  contraction,  but  it  is  more  difficult  than 
Thiersch  grafts,  Avhieh  consist  only  of  the  epidermis.  In  whole  skin  grafting 
the  corium  occupies  relatively  much  more  of  the  graft  than  the  epidermis 
and  consequently  requires  much  more  nutrition  to  keep  it  alive.  The  epi- 
dermis graft,  which  is  the  Thiersch  graft,  is  very  thin,  has  a  large  surface  and 
small  cubical  contents,  and  consequently  requires  but  little  nutrition.  The 
whole  skin  graft  if  reduced  to  many  small  masses,  as  in  the  Reverdin  method, 
or  the  small  deep  skin  grafts  of  J.  S.  Davis,  can  be  used  more  successfully 
than  if  the  Avhole  skin  is  transplanted  in  one  mass.  However,  this  method, 
while  promoting  rapid  healing,  leaves  a  very  conspicuous  scar.  In  the  small 
deep  skin  graft  of  Davis,  not  only  is  the  epidermis  taken  but  also  a  consider- 
able portion  of  the  corium. 

Whenever  skin  grafts  are  used  it  is  always  best  to  take  them  from  the 
patient.  Autografts,  as  these  are  called,  are  much  more  likely  to  be  success- 
ful than  grafts  taken  from  others  of  the  same  race,  which  are  called  iso- 
grafts  or  homo  grafts.  Zoo-grafts  are  grafts  taken  from  lower  animals  and 
invariably  fail  completely,  though  there  may  be  an  appearance  of  success  at 
first. 

Masson,  of  the  Mayo  Clinic,  has  had  considerable  success  with  isografts,  when 
the  donor's  blood  and  that  of  the  patient  have  been  tested  and  proved  to  be  of 
the  same  group.  His  results  in  using  isografts  when  the  red  blood  cells  of  the  do- 
nor were  agglutinated  by  the  serum  of  the  patient  were  always  unsuccessful,  but 
where  this  agglutination  did  not  occur,  the  results  w^ere  satisfactory.  As  a 
rule,  however,  it  is  always  possible  to  get  the  grafts  from  the  patient  and  no 
material  can  be  more  satisfactory  than  this. 

The  wound  on  which  grafts  are  to  be  placed  must  either  be  a  fresh  clean 
wound  or  a  healthy  granulating  surface.  When  the  wound  is  fresh  and  clean 
Thiersch  grafts  will  live  whether  placed  on  fat,  fascia,  tendon,  muscle  or  bone. 
If  the  granulations  are  clean,  firm,  pink  in  color,  and  if  the  bacterial  count 
from  the  wound  secretion  is  very  low  or  negative,  grafts  can  be  transplanted 
directly  to  such  a  granulating  surface  without  any  further  preparation.  If, 
however,  the  granulating  wound  is  infected  or  if  the  granulations  are  too 
exuberant  the  wound  must  be  prepared.  This  may  be  done  by  painting  the 
granulations  with  tincture  of  iodine  or  by  wet  dressings  of  boric  acid  or  salt 
solution.  If,  after  treating  the  wound  in  this  manner  for  a  few  days,  satis- 
factory progress  is  not  made,  the  patient  can  be  given  a  general  anesthetic, 
the  granulating  surface  thoroughly  painted  with  a  tincture  of  iodine,  and  the 
surface  cut  away  with  a  sharp  knife.  This  is  much  better  than  curetting, 
which  bruises  and  may  force  infection  deeph^  in  the  tissues.  Firm 
pressure  Avith  a  dry  gauze  compress  for  at  least  five  minutes  usually  controls 
most  of  the  bleeding.  Any  special  points  that  bleed  at  the  end  of  this  time 
may  have  a  little  longer  pressure  or  may  be  sutured  over  with  fine  plain 
catgut.    It  is  highly  important  that  the  surface  to  receive  the  graft  should  be 


182  OPERATIVE   SURGERY 

dry.     The  wound   is  prepared    in   tliis   niainicr   for   tlic   deep   ^'■raf'ts   of  J.   S. 
Davis,  for  Reverdin  grafts,  or  for  large  wliole  skin  grafts. 

If  the  Reverdin  method  is  used,  pieces  of  epithelium  are  removed  by 
sticking  the  point  of  a  straight  intestinal  needle  into  the  epidermis  and  shav- 
ing off  the  small  piece  of  epidermis  that  is  picked  up  by  the  needle.  In  using 
the  method  of  Davis  of  small  deep  skin  grafts  somcAvhat  the  same  technic  is 
employed.  Davis  uses  a  straight  intestinal  needle  held  in  an  artery  clamp. 
He  has  a  series  of  these  needles  caught  in  clamps  and  picks  up  a  Int  of  the 
skin,  raising  it  so  that  a  little  cone  is  formed.  The  base  of  the  cons  is  cut 
through  with  a  sharp  knife,  going  deep  enough  to  secure  not  only  the  epider- 
mis but  the  corium  also.  The  graft  while  still  on  the  needle  is  transferred 
to  the  wound,  placing  the  raw  surface  next  to  the  Avound.  A  space  of  about 
one-fifth  of  an  inch  is  left  between  each  graft.  They  are  laid  in  definite  rows. 
When  two  rows  have  been  jolaced  they  are  covered  by  strips  of  dry,  sterile 
rubber  protective,  which  is  pressed  firmly  over  the  grafts  with  a  piece  of  gauze. 
The  ends  of  the  protective  extend  beyond  the  wound.  The  protective  may  be 
covered  with  gauze  kept  moist  with  salt  solution,  or  a  paraffined  mosquito 
netting  may  be  laid  on  the  grafts  and  the  latter  covered  Avith  a  dressing. 
Boric  acid  ointment  may  also  be  used.  A  moderate  amount  of  gauze  is  i^laced 
OA'er  the  Avound  and  the  part  is  immobilized  as  much  as  jDossible.  It  is  best 
to  keep  the  patient  in  bed  for  a  feAv  days.  The  first  dressing  should  usually 
be  done  about  the  third  day,  but  in  a  fresh  AA'ound  Avithout  granulations  it  may 
be  postponed  until  the  fifth  or  sixth  day. 

The  method  of  taking  Thiersch  grafts  is  to  shave  off  the  epidermis  Avith 
a  long  sharp  knife  or  razor.  In  order  to  do  this  the  skin  must  be  taut. 
Thiersch  grafts  are  best  taken  from  tlie  thigli,  the  front,  inner,  or  outer  sur- 
faces being  used.  The  skin  can  be  made  tense  Ijy  liolding  it  Avith  dry 
gauze  on  the  upper  part  of  the  thigh,  pressed  firml\-  upward  Avith  the 
open  hand  of  an  assistant,  Avhile  the  operator  Avith  his  left  hand  pulls 
doAvn  the  skin  of  the  thigh  Avith  dry  gauze  and  Avith  his  right  hand  shaves 
off  the  grafts.  If  it  is  desired  to  take  a  large  graft  a  long  amputating  knife 
or  long  kniA'es  made  especially  for  this  purpose  may  be  used  and  it  will  be  nec- 
essai'y  to  have  the  skin  of  the  thigh  fiat.  Tliis  is  l^est  accomplished  l)y  using 
tAvo  boards,  the  skin  being  held  flat  Avith  one,  at  a  point  Avhere  the  graft  is 
started  and  the  other  being  pressed  just  in  front  of  the  advancing  knife. 
The  knife  should  alAvays  be  kept  moist  by  solution  dripping  salt  over  it 
just  before  the  graft  is  cut  and  during  the  process  of  cutting.  Very  large 
grafts  can  be  secured  by  this  method  of  using  a  long  knife  Avith  tAvo  boards, 
Avhich  originated  at  Johns  Hopkins  Hospital.  The  graft,  if  it  is  smooth, 
is  transferred  directly  to  the  Avound  for  Avhich  it  Avas  intended  and  pressed 
into  position  bj'  smooth  moist  gauze.  The  pressure  should  be  firm  and 
a  sloAV  rubbing  motion  is  made  over  the  gauze  to  cause  the  graft  to  ad- 
here to  the  raAV  surface  and  to  exclude  air  bubbles  (Figs.  127  and  128). 
The  grafts  are  laid  as  closely  together  as  possible,  preferably  Avith  the 
edges  OA'erlapping.  If  the  graft  curls  up  it  may  l)e  spread  out  on  sca'- 
eral   laA-ers    of   smooth   gauze,    which    lias   been   Avet    in    salt    solution.      It    is 


PLASTIC    SURGERY 


183 


placed  -willi  llic  r;n\-  side  up  and  \\illi  llie  lin^'cr  it  can  l)e  readily  inicurled  and 
spread  out.  It  is  iIumi  iiuiiiediately  transferred  lo  the  area  that  is  to  be 
grafted  and  pressed  liriuly  into  position.     The  gauze  is  gently  removed,  tak- 


uedLTav/n  iroTn    jj. 


Fig.    127. — Two  boards  used  to   keep  the  skin  tense  while  taking  a  Thiersch  graft,   according   to    the  method 

of  Johns  Hopkins  Hospital. 


Fig.   128. — Thiersch  graft  is  cut  with  a  long  amputating  knife  while  the   wooden  boards  keep  the  skin  tense. 


ing  it  up  first  at  one  corner.     Usually  the  gTaft  Avill  adhere  to  the  wound. 
If,  however,  there  is  any  tendency  for  the  graft  to  stick  to  tlie  gauze,  an 


184  OPERATIVE    SURGERY 

edge  is  loosened  from  the  gauze  with  the  end  of  a  i^robe  or  mosqnito  forceps 
and  held  on  the  wound,  and  then  the  gauze  can  be  removed,  leaving  the 
graft  in  place. 

Some  operators  prefer  to  lay  the  grafts  smoothly  on  a  piece  of  rubber 
protective,  spread  over  a  board,  and  then  transfer  the  grafts  in  this  man- 
ner after  enough  has  been  cut  to  cover  the  whole  surface.  The  raw  sur- 
face of  the  graft  should  not  dry  and  the  sooner  it  is  x^laced  in  contact  with  the 
wound  the  better.  After  the  grafts  are  in  position,  if  there  are  any  bubbles 
caught  under  them  in  spite  of  the  precautions  to  prevent  this,  they  are 
nicked  with  the  point  of  sharp  scissors  and  pressure  is  made  to  expel  the  air. 

There  are  a  number  of  methods  of  dressing  Thiersch  skin  grafts.  Some 
surgeons  prefer  narrow  strips  of  rubber  protective.  Silver  foil  also  makes  a 
good  dressing,  but  it  is  likely  to  break  up  and  if  any  of  the  grafts  fail  to  take  the 
silver  becomes  entangled  in  the  granulations  and  may  discolor  the  scar.  The 
most  satisfactory  dressing  for  Thiersch  grafts  in  my  experience  is  sterile 
strips  of  zinc  oxide  adhesive  plaster.  Zinc  oxide  adhesive  can  be  sterilized 
before  the  crinoline  is  removed  by  putting  it  in  a  steam  sterilizer  with  the 
dressings.  It  is  cut  into  strips  about  an  inch  wide  and  of  a  length  to  extend 
beyond  the  margins  of  the  wound  for  about  one  inch.  The  strips  are  laid  on 
carefully,  beginning  from  the  center  and  placed  so  that  they  barely  touch  each 
other  and  do  not  overlap.  In  this  way  drainage  is  provided.  The  strips 
must  be  applied  carefully,  for  after  they  once  touch  the  grafts  the  grafts  will 
adhere  to  them  and  if  the  strips  are  not  applied  smoothly  the  grafts  will  be 
disarranged.  After  the  wound  is  covered  in  this  manner  dry  sterile  gauze 
is  placed  over  the  adhesive  and  fastened  in  position  by  a  snugly  fitting 
bandage.  The  outer  gauze  dressing  is  removed  three  or  four  days  later,  as 
the  serum,  from  the  wound  makes  the  dressing  stiff  and  may  predispose  to 
infection.  The  gauze  dressing  must  be  taken  off  carefully  so  as  not  to  pull 
up  the  adhesive  strips.  The  adhesive  strips  are  removed  about  ten  days 
after  operation,  when  the  grafts  will  have  taken  firmly.  In  this  manner 
the  numerous  dressings  and  the  necessity  of  moist  gauze  is  clone  away  with  and 
at  the  same  time  advantage  is  taken  of  the  fact  that  adhesive  itself  seems 
to  stimulate  epidermization.  Boric  ointment  is  applied  for  a  week  and  then 
a  dusting  powder. 

In  certain  instances  where  contraction  is  likely  to  be  a  chief  feature  the 
whole  skin  must  be  used.  As  has  been  said  the  deep  skin  or  corium  is  the 
connective  tissue  layer  and  it  is  here  that  contraction  occurs.  Thiersch  grafts 
being  only  the  epithelium  layer  do  not  prevent  the  tendency  to  contraction 
in  a  wound  where  there  is  an  excessive  amount  of  scar  tissue.  The  technic 
of  using  the  whole  skin  graft,  or  the  method  of  "Wolfe-Krause,  has  been 
brought  into  considerable  prominence  recently  by  the  excellent  work  of  H. 
D.  Gillies,  of  England  and  of  J.  S.  Davis,  of  Baltimore.  The  method  of  pre- 
paring the  field  for  the  reception  of  whole  skin  grafts  is  similar  to  that  for 
other  grafts.     All  oozing  must  be  checked  and  it  is  even  more  important  to 


PLASTIC    SURGERY  185 

stop  bleediiis^'  here  than  when  applying  tlie  Thiersch  grafts.  If  the  oozing 
of  the  raw  snrfaee  cannot  be  stopped  it  is  best  to  wait  a  few  days  before 
applying  the  graft.  It  must  be  remembered  that  the  whole  skin  graft 
is  several  times  thicker  than  the  Thiersch  graft  and  consequently  requires 
a  much  greater  blood  supply  for  its  nutrition.  The  whole  skin  grafts  may  be 
applied  on  healthy  granulations  which  are  level  with  the  skin  edges.  If 
pressed  firmly  in  position  on  the  granulations  no  sutures  are  necessary. 

The  technic  as  given  by  Davis  is  to  mark  out  lightly  with  the  scalpel  an 
elongated  ellipse,  Avhich  is  considerably  larger  than  the  raw  surface  it  is  desired 
to  cover,  because  the  graft  contracts  greatly  when  separated.  The  graft  is 
so  shaped  that  the  wound  from  which  it  is  removed  can  be  approximated  by 
sutures  without  great  tension.  The  skin  and  fat  are  removed  down  to  the 
fascia.  Fat  is  trimmed  from  the  grafts  with  curved  scissors  and  the  grafts  are 
perforated  in  several  places  with  a  knife  or  a  saddler's  punch  to  allow  the  es- 
cape of  serum  that  may  collect  under  the  graft.  It  is  best  to  secure  the  graft 
in  position  after  pressing  it  firmly  on  the  wound  by  four  interrupted  su- 
tures and  if  necessary  by  a  continuous  suture  of  horse  hair  or  silk.  Some- 
times the  graft  adheres  so  firmly  that  no  sutures  are  required.  It  should 
be  handled  as  little  as  possible  and  is  placed  in  position  immediately  after 
it  has  been  removed  and  prepared.  The  graft  may  be  cut  in  the  gen- 
eral size  and  shape  of  the  wound  but  it  is  best  to  have  it  not  too  wide.  It 
should  not  be  more  than  one  and  one-half  or  two  inches  in  width  at  its  broad- 
est portion.  If  a  larger  surface  is  to  be  covered  a  long  strip  of  skin  should 
be  taken  and  cut  into  segments  and  the  grafts  laid  side  by  side.  Veins,  if 
exposed,  even  though  they  are  not  injured,  should  be  excised.  Otherwise 
they  may  cause  pain  from  thrombosis  later  on.  It  is  much  more  difficult 
to  secure  success  with  a  whole  skin  graft  than  with  the  Thiersch  graft  for 
reasons  that  have  already  been  mentioned. 

Gillies  thinks  it  best  to  cut  the  graft  in  one  piece  and  of  the  same  size  as  the 
defect  to  be  covered.  In  this  way,  he  believes  the  skin  is  slightly  stretched,  the 
vessels  are  held  open  and  the  transplanted  skin  is  kept  at  its  normal  tension.  The 
graft  is  accurately  held  in  place  by  sutures,  and  firm  pressure  made  over  it,  for 
which  he  recommends  dental  wax.  The  graft  is  perforated  with  a  knife  in  several 
places  to  give  exit  to  serum.  An  adhesive  plaster  dressing,  as  described  for 
Thiersch  grafts  is  a  good  dressing  for  whole  skin  grafts.  Abundant  gauze  and 
firm  pressure  must  be  used. 

Whole  skin  grafts  free  should  not  be  applied  to  bone  or  cartilage,  be- 
cause they  require  too  much  nutrition.  Either  Thiersch  grafts  or  a  whole 
skin  graft  with  a  pedicle  should  be  used  in  such  a  wound. 

About  two  weeks  after  the  graft  has  thoroughly  taken,  gentle  massage 
should  be  started  upon  it  so  as  to  soften  the  graft.  In  wounds  w^here  the 
normal  skin  is  hair  bearing  a  w^hole  skin  graft  of  this  kind  is  made  with  the 
same  technic  that  has  just  been  described.  A  hair  bearing  graft  can  be  taken 
froii]  reo-ipjis  of  the  body  in  which  hair  normally  appears,  as  the  scalp  or  the 


186  OPERATIVE    Sl'RGERY 

pulses.  It  can  be  shaped  for  an  eyebrow  and  Avill  jn-event  a  conspicuous 
deformit}'  wlien  the  eyebrow  has  been  destroyed. 

A  g-raft  transferred  to  Ijone,  as  on  the  skull,  may  not  live  if  the  wound 
is  not  very  vascular  or  is  extensive,.  The  wound  should  be  prepared  for  the 
grafts  a  few  weeks  in  advance  by  drilling  through  the  outer  table  of  the 
skull,  a  series  of  holes  at  close  intervals.  From  these  holes  granulations  will 
spring  and  upon  them  grafts  can  be  laid.  The  granulations  will  furnish  much 
more  abundant  nutrition  to  the  grafts  than  would  the  undisturbed  bone.  This 
method  has  been  developed  and  used  successfully  at  the  ]Mayo  Clinic. 

In  plastic  work  where  the  whole  skin  free  graft,  or  the  pedicle  graft,  or 
sliding  method  is  used  a  depressed  scar  along  the  line  of  union  adds  greatly 
to  the  deformity  no  matter  how  accurately  the  skin  incision  is  made  and 
sutured.  If  there  is  a  depression  and  a  groove  the  scar  will  spread  and  be- 
comes very  conspicuous.  It  is  exceedingly  important  to  prevent  this.  If 
there  is  the  slightest  tension  and  the  sutures  are  improperh'  inserted,  though 
the  immediate  et¥ect  may  appear  satisfactory,  as  healing  and  contraction 
takes  place  it  will  be  seen  that  the  scar  becomes  wider  and  is  depressed. 


-t 


^.^ 


fig    129. The   method  of  Esser  for  preventing  a  sunken  scar.     The   subcutaneous   fat   and   fascia  is   so   in- 
cised as  to   form   a   roll   in  the   middle   of   the   wound. 

Esser*  has  laid  particular  stress  upon  this  and  calls  attention  to  the  im- 
portance of  building  up  the  underlying  fat  and  fascia  before  suturing  the 
skin.  This  may  be  done  by  inserting  the  sutures  so  as  to  catch  a  small  mar- 
gin of  the  skin  and  a  deep  bite  of  the  subcuticular  tissue  on  each  side  of 
the  wound,  thus  approximating  the  subcuticular  tissues  firmly.  If  the  ten- 
sion is  considerable  or  the  desirability  of  an  exceedingly  small  scar  great, 
it  is  best  to  undercut  the  subcuticular  fat  and  fascia  on  each  side  of  the 
wound  and  bring  the  fat  and  fascia  together  by  fine  plain  catgut  sutures, 
so  forming  a  slight  ridge  just  under  the  line  where  the  skin  is  to  be  sutured 
(Fig.  129).  This  procedure  will  make  the  line  of  incision  apparently  bulge 
a  little,  but  as  healing  and  contraction  occur  the  ridge  will  disappear  and 
the  scar  will  be  on  the  normal  level  of  the  skin  instead  of  being  depressed  and 
contracted.  This  is  a  highly  important  point  when  excising  any  scar  that 
has  been  depressed  and  is  adherent  to  the  tissues  underneath.  If  the  depres- 
sion is  too  great  to  be  corrected  in  this  manner,  there  should  be  transplanted 
a  small  amount  of  fat,  preferably  on  a  pedicle  from  the  undermined  skin 
in  the  region  of  the  wound,  or,  if  necessary,  a  free  transplant  of  fat  from  the 
thigh  can  be  used. 


*Surg.,   Gynec.   S:  Obst.,   June,   1917. 


CHAPTER  XIV 
OPERATIONS  OX  THE  FACE  AND  MOUTH 

Suryery  of  the  face  consists  largely  of  either  plastic  surgery  or  the  excis- 
ion of  tumors.  The  congenital  defects  of  the  face  and  mouth  most  frequently 
reiiuiring  operations  are  harelip  and  cleft  palate. 

Operations  for  harelip  have  an  ancient  and  honorable  history.  There 
has  not  been  the  same  change  in  technic  that  has  occurred  in  abdominal  and 
closed  Avounds  where  aseptic  surgery  can  be  practiced  and  where  sepsis  as  a 
complication  is  avoided  by  the  proper  technic  and  after-treatment. 

In  operations  on  the  mouth  and  lips  no  dressing  can  be  applied.  Much 
can  be  done,  however,  by  preparing  the  mouth  and  lips  and  by  treating  the 
teeth  for  several  days  before  the  operation  by  careful  cleansing  with  water  and 
mild  antiseptics.  Of  course  the  regular  te:-hnic  of  aseptic  surgery  is  followed, 
but  particular  care  is  taken  to  maintain  the  nutrition  of  the  tissues,  to  make  a 
sharp  clean  dissection  wherever  possible,  and  to  avoid  injury  to  the  lines  of  the 
wound.  As  the  wound  cannot  be  sealed  against  infection  from  food  or  air,  partic- 
ular reliance  must  be  placed  upon  these  measures  in  order  to  maintain  the  resist- 
ance of  the  tissues  against  infection  and  their  maximum  ability  for  satisfac- 
tory and  rapid  repair. 

The  principles  that  underlie  operations  for  harelip  and  cleft  palate  are 
those  that  have  already  been  discussed  in  the  chapter  on  Plastic  Surgery. 
The  parts  must  be  mobilized  as  thoroughly  as  possible.  An  occasional  drawn 
or  unnatural  fixation  of  the  upper  lip  is  due  to  the  fact  that  the  tissues 
were  not  thoroughly  mobilized  before  suturing.  Any  operation  on  a  harelip 
must  be  preceded  by  a  dissection  of  the  ala  of  the  nose  and  the  adjoining  por- 
tion of  the  lip  from  the  maxillary  bone  until  the  sides  of  the  cleft  fall  easily 
in  contact  with  each  other  without  tension.  The  mucosa  under  the  lip 
on  the  outer  side  of  the  cleft  is  cut  with  scissors  or  knife.  The  rest  of  the 
mobilizing  dissection  is  done  partly  by  spreading  the  blades  of  the  scissors 
when  there  is  little  resistance,  and  partly  by  sharp  dissection.  A  plug  of 
dry  gauze  is  inserted  immediately  after  dissection  and  pressure  is  made  to 
stop  the  bleeding.  The  pressure  can  be  maintained  by  the  fingers  of  an  assistant 
until  the  bleeding  has  ceased.  There  is  no  occasion  for  any  apparatus  to 
clamp  the  lip  in  order  to  reduce  the  flow  of  blood  from  the  coronary  arteries. 
This  is  best  done  by  the  fingers  of  an  assistant.  The  lip  should  not  be  pared 
until  the  operator  is  ready  to  insert  sutures. 

In  incomplete  clefts  often  a  transverse  incision  which  is  sutured  in  the 
opposite  direction  from  that  in  which  it  is  made  will  give  satisfactory  re- 

1S7 


188  OPERATIVE    SURGERY 

suits.  This  depends,  hoAvever,  upon  the  character  of  the  lip.  If  the  tissue 
just  above  the  notch  of  the  cleft  is  thin  and  poorly  developed  it  will  be  much 
better  to  excise  this  tissue  and  convert  the  incomplete  harelip  into  one  ex- 
tending into  the  nostril.  The  tissues  should  be  cut  widely  enough  to  reach  a 
lip  of  normal  thickness.  Nothing  is  more  disfiguring  than  to  unite  thin  tissue 
while  on  either  side  of  the  sear  is  a  lip  of  normal  thickness.  Paring  of  the  cleft 
is  done  with  a  view  to  securing  a  broad  raw  surface  for  apposition.  If  there 
is  any  doubt  about  this  the  lip  is  pared  farther  from  the  cleft  until  well  de- 
veloped tissue  is  found  or  else  the  pared  wound  is  split  with  an  incision  so  as 
to  flare  it  open,  turning  the  mucosa  in  and  the  skin  out,  and  thus  giving 
a  wide  raw  surface  for  approximation.  Such  a  procedure,  however,  is  not 
often  necessary. 

The  anesthetic  is  ether,  given  during  the  operation  by  pumping  ether 
vapor  through  a  bent,  perforated  metal  tube  which  is  placed  in  the  corner  of 
the  mouth.  Aside  from  the  simple  procedure  of  a  transverse  incision  above 
the  notch  in  the  lip  which  is  sewed  up  in  the  opposite  direction  to  the  in- 
cision there  are  a  number  of  operations  for  harelip.  This  transverse  incision 
can  sometimes  be  made  just  below  the  nostril,  as  advocated  by  C.  H.  Mayo, 
and  the  scar  will  be  less  conspicuous  than  if  made  close  to  the  margin  of  the 
mucous  membrane.  In  spite  of  the  multiplicity  of  more  or  less  complicated 
operations  for  harelip  usually  two  or  three  can  be  made  to  fill  any  require- 
ment. The  important  points  to  be  borne  in  mind  are  to  approximate  the 
tissues  without  tension,  to  have  the  vermilion  border  of  the  lip  a  continu- 
ous smooth  line,  and  to  have  the  lip  at  the  line  of  incision  slightly  longer 
than  normal  to  allow  for  subsequent  contraction  when  the  wound  heals. 

If  there  is  a  reasonable  abundance  of  healthy  lip  tissue  of  normal  thick- 
ness on  either  side  of  the  cleft  probably  no  operation  is  more  satisfactory  than 
the  Rose  operation  or  some  of  its  modifications.  The  Eose  operation  re- 
quires a  curved  incision  which  is  more  difficult  to  make  than  an  angular  in- 
cision. After  thoroughly  mobilizing  the  lip  an  incision  is  made  with  a  sharp- 
pointed  knife  from  the  apex  of  the  cleft  along  the  outer  margin  downward  and 
outward  to  a  point  about  one-eighth  inch  above  the  vermilion  border.  From 
the  lower  extremity  of  this  incision  another  cut  is  made  almost  at  a  right 
angle  to  the  first  incision  and  going  sharply  inward  and  downward.  The 
first  incision  is  about  one-eighth  inch  shorter  than  the  length  of  the  proposed 
upper  lip.  Similar  incisions  are  made  on  the  other  margin  of  the  cleft  and 
the  bleeding  is  controlled  by  pressure  on  the  lip  with  the  fingers  and  thumb  of  an 
assistant  (Fig.  130).  The  incision  gees  well  through  the  skin  and  down  to  the 
mucosa.  It  is  difficult  to  cut  the  under  surface  of  the  mucosa  smoothly  with 
a  kjiife  and  this  part  of  the  incision  can  best  be  finished  with  sharp  scissors. 
A  tractor  suture  of  fine  silkworm-gut  is  inserted  into  the  lowest  portion  of  the 
mucosa  of  the  lip.  This  suture  is  not  tied,  but  tlie  ends  are  left  long  and 
clamped  with  a  mosquito  forceps.  It  is  used  as  a  tractor  suture  and  by  gen- 
tle traction  the  rest  of  the  lip  is  thrown  into  easy  apposition.  A  suture  of 
fine  silkworm-gut  is  then  inserted,  beginning  close  to  the  margin  of  the  wound 


FACE   AND    MOUTH 


189 


and  at  the  angle  made  by  the  junction  of  the  two  incisions.  The  insertion 
of  this  suture  is  exceedingly  important.  It  is  made  with  a  small  sharp  needle, 
preferably  a  curved  needle,  and  the  suture,  after  penetrating  the  skin  close  to 
the  wound,  goes  well  out  into  the  tissues  of  the  lip  and  then  comes  back  taking 
a  small  margin  of  the  mucosa.  The  bite  this  stitch  takes  in  the  mucosa  is  im- 
portant. If  it  catches  the  mucosa  too  far  toward  the  nostril  it  will  force  the 
vermilion  border  to  the  lower  end  of  the  skin  incision ;  consequently,  the  mucosa 
should  be  caught  near  the  lower  portion  of  the  w^ound  to  prevent  the  forcing 
of  a  redundant  amount  of  mucosa  toward  the  skin  part  of  the  incision.  This 
suture  is  carried  over  to  the  other  side  and  inserted  in  a  similar  manner,  only 
it  goes  from  the  mucosa  to  the  skin,  taking  care  on  this  side  also  to  catch 
the  mucosa  at  the  proj^er  place  near  the  lower  end  of  the  incision,  to  take  a 
large  bite  of  lip  tissue  and  a  small  bite  of  skin.  It  emerges  at  the  angle  made 
by  the  two  incisions.    This  suture  is  tied  snugly  but  not  too  tightly  and  the  ends 


Fig.    130. — A    modified    Rose    incision    for    a    single 
harelip. 


Fig.    131. — The    sutures    have    been    placeil    and    all 
are   tied    except   the   tractor    snture. 


are  left  long  until  the  next  suture  is  applied.  The  third  suture,  also  fine  silk- 
worm-gut, is  placed  near  the  nostril  and  penetrates  the  whole  thickness  of  the 
lip.  The  next  suture  unites  carefully  the  vermilion  border  of  the  lip.  This 
is  done  while  making  traction  on  the  tractor  suture.  This  suture  may  be  of  silk- 
worm-gut or  fine  silk,  preferably  arterial  silk.  As  many  other  sutures  of  fine 
arterial  silk  are  inserted  as  is  necessary  to  secure  satisfactory  approximation. 
The  stitches  in  the  skin  are  placed  first,  then  those  in  the  mucosa  (Fig.  131). 
Lastly,  the  tractor  suture  is  tied,  if  tissues  which  it  embraces  have  not  been 
too  much  damaged  by  the  traction.  If  so,  sutures  of  fine  arterial  silk  are  in- 
serted near  the  tractor  suture  to  maintain  apposition  of  the  mucosa  and  the 
tractor  suture  is  removed.  The  nostril  should  be  approximated  accurately. 
Sutures  are  often  carried  too  far  into  the  nostril  and  so  occlude  it.  The  nostril 
should  be  made  symmetrical  with  the  normal  nostril,  but  it  is  better  to  have  it 
flare  open  slightly,  a  defect  which  can  be  easily  remedied  by  a  subsequent 


190 


Ol'ERATIVE    RrnOKRY 


stitch,  than  to  have  it  too  tiylit,  as  this  is  much  more  difficult  to  correct.  Al- 
lowance should  always  be  made  for  contraction  along  tlie  line  of  scar  and  the 
lip  should  be  made  slightly  louger  than  appears  to  be  normal. 

If  the  tissues  in  the  neighborhood  of  the  cleft  are  quite  thin  and  too  much 
tension  would  result  if  thin  tissues  were  entirely  sacrificed,  the  Owen  operation 
can  be  done.     This  operation  is  also  indicated  when  the  cleft  of  the  harelip  is 


iiiiipiii 


Fig.     132. — An    incision    for    harelip    according    to 
the   method   of    Owen. 


Fig.    133. — Sutures    in    the   vertical    incision    of 
Owen   are   placed. 


Fig.    134. — The    last    sutures    are    placed    in    the 
operation    of   Owen. 


unusnally  wide.  The  method  of  procedure  is  best  indicated  in  the  accompanying 
illnstrations.  The  lip  is  well  mobilized  as  already  described.  The  outer  margin 
of  the  cleft  of  the  harelip  is  pared  from  the  nostril  to  the  corner  of  the  month, 
the  incision  making  a  decided  angle  at  a  point  about  halfway  between  the  nos- 
tril and  what  would  be  the  vermilion  border  of  a  normal  lip.  The  incision  on 
the  other  side  of  the  cleft  begins  at  the  nostril  and  goes  downward  along  the 


FACE    AM)    MOI'I'II 


191 


cleft  to  about  opposite  tin'  aii^lc  of  the  incision  on  tlic  outer  side,  tlieu  it 
turns  transverst'ly  away  from  tlie  eleft,  ondin-i'  alxiut  midway  between  the 
normal  nostril  and  the  lower  border  of  the  upper  lip  (Fig.  132).  A  suture  for 
fixation  is  inserted  in  such  a  manner  that  it  brings  together  these  two  ineisions 
just  at  the  i)oint  where  they  turn  outward  from  tlie  cleft  of  the  liarelip  (Fig. 
133).  A  second  fixation  sutui'e  unites  the  tip  of  the  flap  containing  the  mucous 
membrane  to  the  corner  of  the  mouth.  The  nostril  is  approximated  hy  a  third 
fixation  suture  and  the  rest  of  the  wound  is  closed  by  interrupted  or  contiiui- 
ous  sutures  of  fine  silk  or  horsehair   (Fig.  134). 

Double  harelip  is  often  accompanied  by  a  prominent  intermaxillary  bone. 
In  such  instances,  it  will  be  necessary  first  of  all  to  replace  the  intermaxillary 
bone,  which  should  never  be  cut  away.  This  is  done  by  making  a  submucous 
resection  of  a  part  of  the  septum  which  supports  the  intermaxillary  bone.  An 
incision  is  made  along  the  lower  border  of  this  septum,  the  mucosa  is  stripped 
up  on  each  side  and  a  sufficient  amount  of  the  septum  is  cut  away  with  scissors 
or  bone  forceps  to  enable  the  intermaxillary  bone  to  be  pressed  into  position 
between  the  two  maxillary  bones   (Fig.  135).     The  outer  edges  of  the  inter- 


Fig.   135. — Line   of   incision   for   excision    ot   nasal   septum. 

maxillary  bone  are  pared  with  a  sharp  knife  and  the  corresponding  sides  of  the 
maxillary  bones  are  similarly  freshened.  The  lip  on  the  outer  sides  of  the 
cleft  is  freely  dissected  from  the  maxillary  bone.  With  a  stout  perineal  needle, 
with  the  eye  at  the  point,  in  infants,  or  with  a  drill  in  older  children,  a  hole  is 
made  about  one-fourth  to  one-half  inch  from  the  margin  of  the  cleft  above  the  al- 
veolar process  and  through  the  maxillary  bone  into  the  mouth,  coming  out  about 
the  junction  of  the  hard  palate  with  the  alveolar  process.  The  direction  of  the 
perforation  is  slightly  downward,  as  well  as  inward  and  backward.  In  this  w^ay 
a  good  hold  is  obtained  on  each  maxillary  bone  and  at  the  same  time  the  matrices 
of  future  teeth  are  uninjured.  A  wire  is  passed  through  these  perforations.  If 
a  perineal  needle  is  used  the  wire  is  threaded  into  the  eye  of  the  needle  as  it 
appears  in  the  mouth.  A  moderately  stout  bronze  ware  may  be  used,  though 
braided  or  cable  bronze  wire  is  preferable  and  is  easily  tied.  One  end  of  the 
wire  is  carried  across  the  front  surface  of  the  intermaxillary  bone  with  the 
perineal  needle,  going  just  beneath  the  lip  tissue  that  covers  this  bone.  The 
bone  is  pressed  into  position  and  the  wire  adjusted  accurately  either  by  twist- 


192 


OPERATIVE    SURGERY 


ing,  if  it  is  solid  wire,  or  by  tying,  if  it  is  braided  or  cable  wire.     The  double 
harelip  can  then  be  repaired  or  this  can  be  done  at  a  different  sitting. 

The  intermaxillary  bone  should  not  fit  too  far  into  the  defect  that  exists 
between  the  anterior  portions  of  the  maxillary  bones  because  it  will  pull  the 
nose  doAvn  too  low,  and  also  because  the  intermaxillary  bone  will  gradually  be 
pressed  further  in  after  the  double  harelip  is  repaired. 

If  there  is  a  marked  cleft  of  the  alveolar  process  and  hard  palate  in  an  infant 
with  single  harelip,  an  effort  should  be  made  to  close  the  front  of  this  cleft  in  a 
somewhat  similar  manner  before  repairing  the  harelip.  The  wire  is  inserted  as 
has  just  been  described  and  is  twisted  or  tied  while  the  margins  of  the  cleft  in  the 
alveolar  process  are  forced  together  by  the  hands  of  an  assistant  on  each  cheek. 
In  this  way  the  anterior  part  of  a  cleft  in  the  hard  palate  can  be  brought 
together  or  greatly  reduced,  and  a  single  wire  suture  thus  placed  will  secure 
much  of  the  benefit  Avithout  the  added  danger  that  is  derived  from  multiple 
Avire  sutures  inserted  farther  back  through  the  cleft. 


Fig.    136. — Lines   of   incision    for    double    harelip. 


Fig.    137. — Double   harelip   operation   completed   ex- 
cept for  insertion  of  additional   sutures. 


Practically  all  double  harelips  can  be  repaired  by  a  slight  modification  of 
the  operation  for  single  harelip.  The  only  differences  are  that  the  margins  of 
the  lip  on  the  intermaxillary  bone  are  pared  to  make  a  broad  wounded  sur- 
face and  an  outward  relaxation  incision  of  about  one-fourth  inch  is  made  from 
the  angle  formed  by  the  meeting  of  the  two  incisions  used  for  paring  the  mar- 
gins of  the  cleft,  as  has  been  described  under  single  harelip  (Fig.  136).  In 
this  way  two  flaps  consisting  of  the  vermilion  border  of  the  lip  with  the  ad- 
jacent skin  are.  mobilized  and  can  be  readily  sutured  together  just  under  that 
part  of  the  lip  on  the  intermaxillary  bone.  Fixation  sutures  are  placed  at  each 
nostril  and  also  at  the  points  connecting  the  lower  margins  of  the  lip  on  the 
intermaxillary  bone  to  the  adjacent  portions  of  the  pared  lip  (Fig.  137). 

After  repairing  a  double  harelip  in  this  manner  the  columna  is  markedly 
pulled  down  by  the  new  position  of  the  intermaxillary  bone  so  that  the  tip  of 
the  nose  is  drawn  forcibly  down  to  near  the  level  of  the  lip.     There  is  a  great 


FACE    AND    MOUTH 


im 


tcmi)ta1i()n  1o  t'orrcL't  this  by  an  immediate  operation  on  the  cohnuiia.  Blair, 
however,  has  caUed  attention  to  the  t'aet  tliat  the  colnnma  will  gradually 
lengthen  and  release  the  tip  of  the  nose  and  that  such  operations  are  usually 
unnecessary,  particularly  in  infants. 


138. — David   R.,   ten   months   old.     Photograph 
taken    before    operation. 


Pig.  139.— David  R.,  shown  in  Fig.  138.  Photo- 
graph taken  four  months  after  operation.  The 
patient  also  hat'  a  complete  cleft  of  the  palate 
which   was    cured   by    operation. 


Fia 


140. — Bessie   H.,    three   weeks   of   age. 
lip    and   complete   cleft   of   palate. 


Hare- 


Fig.  141. — Same  patient  shown  in  Fig.  140. 
Photograph  taken  two  years  and  seven  months 
after  the  operation.  Palate  had  also  been  closed 
by   operation. 


No  dressing  is  i)laced  upon  the  wound  which  is  merely  dusted  with  boric 
acid  powder.  This  becomes  incorporated  with  the  serum,  hardens  and  forms 
a  protective  sealing.  The  tension  on  the  harelip  is  largely  taken  up  by  the  fixa- 
tion sutures  and  no  appliance  to  relieve  tension  is  necessary.     The  fine  stitches 


194 


OPERATIVE    SURGERY 


are  removed  after  four  or  five  days.  The  fixation  sutures,  however,  should 
not  be  removed  under  seven  or  eight  da3^s  and  unless  the  wound  is  quite  firm 
maj^  be  left  even  longer.  While  less  scar  from  the  stitches  occurs  if  they  are 
removed  soon,  the  tissues  need  the  support  of  the  stitches  and  will  stretcli 
unduly  without  them,  so  that  the  scar  along  the  line  of  incision  will  be  made 
more  conspicuous  if  the  fixation  sutures  are  removed  too  soon  (Figs.  138,  139, 
140,  141,  142  and  148). 

There  is  much  discussion  as  to  the  age  at  which  harelips  and  cleft  palates 
should  be  operated  upon.  A  harelip  should  be  corrected  early.  If  the  baby 
is  vigorous  it  msLj  be  done  even  a  few  hours  after  birth.  "When  the  baby  is 
two  or  three  weeks  old,  however,  seems  to  be  almost  an  ideal  time.  If  a  cleft 
palate  extends  through  the  alveolar  process  the  anterior  part  should  be  cor- 


-Ilerbert   T.,  age  seven  months, 
harelip   and   cleft  palate. 


Double 


Fig.  143. — Same  patient  shown  in  Fig.  142. 
Photograph  taken  two  years  and  three  months 
after   operation. 


rected  at  the  same  time  the  harelip  is  repaired.  This  will -greatly  narrow  the 
cleft.  The  rest  of  the  cleft  can  be  repaired  from  two  to  six  months  later  if 
the  patient  is  in  good  condition.  None  of  these  patients  should  be  operated  upon 
until  their  general  health  has  been  brought  up  as  much  as  possible.  The  hare- 
lip patient  should  be  examined  a  few  months  after  the  operation.  Not  infre- 
quently a  slight  irregularity  of  the  lip  will  then  be  noticed,  which  was  not  ap- 
parent immediately  after  healing.  The  contraction  in  the  line  of  the  scar  may 
be  unduly  great  and  may  produce  a  slight  notch  or  sometimes  one  side  will  pull 
up  where  it  has  been  mobilized  and  elevate  the  vermilion  border.  All  of  these 
changes  will  occur  within  a  few  months  after  the  operation  and  they  can  be 
readily  remedied  by  a  simple  procedure  which  will  make  the  lip  practically  nor- 
mal. If  the  mucosa  of  the  lip  has  pulled  up  into  the  incision  this  can  be  cor- 
rected by  the  excision  of  a  small,  broad,  diamond-shaped  area,  so  planned  and 
sutured  that  the  excess  of  mucosa  is  removed  and  the  margins  of  the  skin 


FACE    AND    MOUTH 


195 


are  brought  together  in  siieli  a  manner  as  to  make  the  vermilion  l)order  of  the  lip 
continuous  and  straight.  The  sutures  used  are  fine  arterial  silk  or  horsehair. 
If  the  skin  on  one  side  has  pulled  up  more  than  on  the  other,  excision  of  the 
triangular  redundant  portion  of  the  mucosa  with  a  slight  extension  of  the 
incision  upward  along  the  line  of  the  old  skin  incision,  and  undercutting  the 
skin  in  the  neighborhood  will  enable  the  defect  to  be  corrected  by  drawing  the 
skin  to  its  normal  level.    All  these  defects  should  be  somewhat  overcorrected. 

CLEFT  PALATE 

The  great  majority  of  cleft  palates  can  be  repaired  by  adapting  the  flap 
sliding  principle  of  plastic  operations.  This,  the  Langenbeck  operation,  has 
been  developed  and  emphasized  by  Berry  and  Legg  and  by  Blair  who  have  ob- 
tained excellent  results.  It  is  particularly  applicable  in  clefts  with  a  high 
arch.  It  undoubtedly  comes  nearer  returning  tissue  to  their  physiologic  nor- 
mal than  complicated  plastic  procedures  in  which  flaps  are  inverted,  such  as 
the  method  of  Lane. 

The  anterior  portion  of  a  cleft  in  the  hard  palate  in  an  infant  or  a  young 
child  should  be  closed  or  diminished  as  much  as  possible  while  the  bones  are 
soft  by  the  insertion  of  a  single  wire  suture  as  described  under  operations  on 
harelip.  If  a  harelip  is  present  this  wire  is  placed  before  repairing  the  harelip. 
The  whole  cleft  in  the  bony  palate,  and  particularly  that  in  the  front  part,  is 
greatly  diminished  by  this  single  wire  suture.  It  seems  to  accomplish  most 
of  the  good  that  is  obtained  by  the  multiple  wire  sutures  and  is  followed  by 
less  danger  of  necrosis  than  w^ien  multiple  wire  sutures  are  applied. 

The  operation  of  Lane  in  which  a  wide  flap  is  taken  from  one  side  of  the 
cleft  with  the  hinge  on  the  margin  of  the  cleft  and  turned  over  and  into  a 
pocket  made  by  dissecting  up  soft  tissues  on  the  opposite  side  of  the  cleft,  at  one 
time  had  many  advocates.  There  are  serious  objections  to  this  operation,  how- 
ever. It  exposes  a  large  amount  of  raw  surface  and  is,  consequently,  followed 
by  extensive  scar  tissue.  While  union  is  more  likely  to  occur  after  such  an 
operation  than  after  the  flap  sliding  operation  of  Langenbeck  as  advocated 
by  Berry  and  Legg,  the  late  results  are  frequently  unfortunate  and  the  exces- 
sive scar  tissue,  while  closing  the  actual  cleft,  probably  functions  but  little 
better  than  would  a  rubber  obturator.  The  late  results  of  the  Lane  operation, 
at  least  in  my  hands,  have  not  been  satisfactory  so  far  as  obtaining  good  func- 
tional use  of  the  soft  palate  is  concerned. 

The  difficulties  in  using  the  Langenbeck  flap  sliding  operation  are  in  cases 
with  a  low  palate  arch  and  those  with  a  wide  defect.  In  such  instances,  how- 
ever, as  has  been  shown  by  Blair,  much  can  be  accomplished  by  making  an  in- 
cision in  the  hard  palate  just  internal  to  the  alveolar  process,  stripping  up 
the  mucoperiosteal  flaps  from  the  bone,  and  separating  the  attachment  of  the 
soft  palate  to  the  bony  palate  as  though  a  complete  palate  operation  would  be 
done,  but  instead  of  paring  the  edges  of  the  cleft  and  placing  sutures,  these  in- 
cisions are  packed  with  gauze  saturated  in  ten  per  cent  solution  of  colloidal 


196 


OPERATIVE    SURGERY 


silver  and  stitched  in  place.  After  doing  this  Blair  advocates  operating  four 
days  later  at  which  time  there  is  a  maximum  amount  of  approximation  of  the 
flaps.  If  the  operation  is  still  further  postponed  shrinkage  of  the  flaps  will 
occur. 

Probably  the  best  suture  material  for  cleft  palates  is  fine  silver  wire  No. 
29  or  Xo.  30.  This  can  be  inserted  with  fine  curved  needles  held  in  the  tip 
of  a  hemostat  or  a  small  needle  holder.  If  the  needles  are  sharp  the}'  can  be 
manipulated  satisfactorily.  The  advantage  of  silver  wire  is  that  it  is  mildly 
antiseptic  and  so  tends  to  prevent  infection,  which  is  the  bane  of  cleft  palate 
work,  and  also  it  can  be  very  accurately  adjusted.  It  is,  of  course,  impossible 
to  use  coarser  silver  wire  for  such  work,  but  the  fine  wire  can  be  accurately 
twisted  and  if  a  suture  appears  too  tight  it  can  be  relaxed,  while  if  it  is  not 
tight  enough  it  can  be  tightened  by  au  extra  twist.  Mosquito  forceps  are  very 
useful  in  this  work.  These  and  a  sharp-pointed  knife,  together  with  a  periosteal 
elevator,  one  end  of  which  is  bent  at  a  right  angle,  are  the  chief  instruments  that 
are  needed. 

The  patient  is  placed  with  the  head  well  back  and  in  a  good  light.  The 
tip  of  each  half  of  the  uvula  is  caught  with  a  mosquito  forceps.  One  side  is 
held  taut  and  with  a  sharp-pointed  knife  the  mucosa  at  the  front  angle  of  the 
cleft,  if  it  is  not  a  complete  cleft,  is  transfixed  and  a  thin  ribbon  of  tissue  is 
cut  off  from  this  point  to  the  tip  of  the  uvula.  The  same  procedure  is  repeated 
on  the  opposite  side.  An  incision  is  then  made  just  internal  to  the  posterior 
portion  of  the  alveolar  process  of  the  upper  jaw.  This  hugs  the  alveolar  proc- 
ess closely  and  is  extended  slightly  around  its  posterior  portion.  In  this 
manner  the  descending  palatine  artery  is  avoided  and  the  nutrition  of  the  flap, 
which  is  essential  to  successful  union,  is  preserved  (Fig.  144).  A  small  peri- 
osteal elevator  is  inserted  into  the  incision  and  the  mucoperiosteal  flap  is  raised. 
This  is  done  as  gently  as  possible  so  as  to  separate  the  tissues  without  too  much 
injury  to  the  flap.  The  tip  of  the  elevator  is  pushed  through  to  the  cleft  and 
is  carried  by  a  rocking  motion,  first  forward  and  then  backward  to  the  soft 
palate.  It  is  very  important  to  separate  the  attachment  of  the  soft  palate  to 
the  bone  of  the  hard  palate.  This  is  best  accomplished  with  curved  scissors, 
injury  to  the  soft  palate  and  the  mucoperiosteal  flap  being  -prevented  by  re- 
traction of  this  flap  with  a  hook  or  with  the  tip  of  the  finger.  Division  can  also 
be  made  with  the  tip  of  a  sharp  knife  which  cuts  from  below  upward.  Some- 
times the  division  can  be  made  by  curved  scissors  through  the  relaxation  in- 
cision. It  is  vital  for  the  success  of  the  operation  that  this  attachment  be  thor- 
oughly separated. 

The  suture.s  are  noAv  placed,  inserting  the  first  suture  about  the  point 
of  junction  between  the  soft  palate  and  the  mucoperiosteal  portion  of  the  hard 
palate.  This  suture  of  fine  silver  wire  is  not  tied  but  the  two  ends  are  clamped 
and  aid  in  exposing  the  margins  of  the  cleft  for  further  sutures.  Tliree  or  four 
other  sutures  are  placed  in  the  soft  palate  and  as  many  more  anteriorly.  They 
may  be  twisted  as  they  are  placed.  At  the  tip  of  the  uvula  a  suture  is  twisted 
and  cut.     Sometimes  the  sutures  are  more  easily  placed  by  having  a  needle  on 


FACE    AND    MOUTH 


197 


eacli  ciul.  It  is  liiulily  iinpoi'taiit  that  the  sutures  aj)pr()XLniatiiig  the  edges  of  the 
wound  should  not  be  under  tension.  If  the  general  tension  appears  too  great  the 
original  relaxation  incision  should  be  continued  either  forward  or  backward 
and  the  flaps  more  thoroughly  mobilized  (Fig.  145).  It  may  occasionally  be 
wise  to  insert  one  relaxation  stitch  in  a  large  curved  sharp  needle  about  where 
the  soft  palate  joins  the  mucoperiosteal  portion  of  the  hard  palate.  This  should 
be  of  silver  wire  and  twisted  to  one  side  of  the  wound.  This  suture  is  very 
infrequently  required  and  diminishes  the  nutrition  to  the  margins  of  the  wound. 
The  ends  of  the  wire  are  cut  and  are  left  slightly  protruding.  In  this 
way  the  wound,  particularly  in  infants,  will  be  protected  from  the  tongue. 
The  mouth  should  be  systematically  cleaned  for  some  days  before  operation  but 
it  is  doubtful  if  the  application  of  any  antiseptic  at  the  time  of  operation  is 


Fig.  144. — Lines  of  incision  for  relaxation  in 
the  operation  for  cleft  palate.  A  ribbon  of  tissue 
is  being  cut  from  the  margins  of  the   cleft. 


145. — Cleft   palate   operation   completed. 


beneficial  and  it  may  be  irritating.  The  anesthetic  of  ether  is  maintained  by  a 
curved  metal  tube,  which  is  placed  in  the  corner  of  the  mouth  while  ether  vapor 
is  sprayed  through  the  tube.     This  also  has  an  antiseptic  value. 

If  the  cleft  is  complete  and  the  bones  are  too  well  developed  for  the 
anterior  portion  to  be  closed  by  a  wire  suture,  this  portion  is  left  for  a 
subsequent  operation,  because  if  too  much  is  undertaken  at  first  the  nutrition 
of  the  flaps  will  be  imperiled.  After  about  four  weeks  the  anterior  portion  of 
the  cleft  is  repaired  by  turning  over  a  limited  flap  after  the  general  method 
of  Lane.  In  this  portion  of  the  cleft,  where  the  only  function  of  the  palate  is 
to  act  as  an  obturator,  there  is  not  the  same  objection  to  the  operation  of  Lane 
as  in  the  posterior  portion  where  muscular  action  is  essential  for  the  proper 
functioning  of  the  palate.  Here  a  pocket  is  created  by  undermining  one 
side  of  the  cleft  from  an  incision  along  its  edge.     A  flap  is  taken  on  the  op- 


198 


OPERATIVE   SURGERY 


posite  side  with  its  hinge  along  the  margin  of  the  cleft  and  is  tiii'ned  over 
and  tucked  into  the  pocket  and  fastened  in  position  with  sutures. 

If  a  cleft  is  so  wide  or  the  arch  so  low  that  the  flap  sliding  method  of 
Langenbeck  cannot  be  applied,  the  Lane  operation  may  be  attempted.  If  the 
patient  is  an  infant  and  the  teeth  have  not  erupted  a  wide  flap  can  be  obtained 
from  the  buccal  mucosa  and  the  alveolar  process.  In  older  patients  with  teeth, 
a  flap  from  the  anterior  portion  of  the  buccal  surface  of  the  cheek  is  impossible, 
but  a  flap  may  be  turned  down  from  the  mucosa  with  a  pedicle  posterior  to  the 
alveolar  process  or,  as  practiced  by  Blair,  a  flap  may  be  taken  from  the  neck, 
carried  into  the  mouth  between  the  teeth,  and  fastened  across  the  cleft.  A 
permanent  gag  is  placed  between  the  teeth  to  prevent  injury  to  the  flap,  and 
after  a  few  weeks  when  the  nutrition  of  the  flap  is  established  in  the  mouth 
the  pedicle  is  severed.  The  cleft  is  closed  by  the  transplant  after  a  series  of 
readjustment  operations. 

THE  LIPS 

Surgery  of  the  lips  consists  largely  of  plastic  surgery.  Operations  for 
congenital  deformities  have  already  been  considered.  Plastic  operations  on 
the  lip  may  be  for  acquired  deformities,  either  from  accidental  trauma  or 
from  removal  of  malignant  disease.     Operations  for  cancer  should  be  planned 


(/^f^^ 


Fig.    146. — Eines    of    incision    for    repair    of    upper 
lip    by    method    of   Denonvilliers. 


Fig.    147. — Operation    of    Denonvilliers    completed. 


primarily  with  a  view  to  curing  the  cancer  and  the  cosmetic  effect  should 
be  a  secondary  and  a  different  consideration.  Halsted  has  observed  that 
if  the  surgeon  who  operates  for  cancer  did  not  attempt  to  close  the  de- 
fect, but  left  this  for  someone  else,  all  temptation  to  leave  conditions  favor- 
able for  a  closure  of  the  wound  would  be  removed,  more  cancers  would 
be  cured,  and  plastic  operations  after  removal  of  cancer  would  fall  into  the 
same  general  category  as  accidental  trauma. 

The  upper  lip  is  rarely  the  site  of  malignant  disease,  whereas  cancer  of 
the  lower  lip  is  common,  so  reconstruction  of  the  upper  lip  aside  from  con- 
genital deformity  is  called  for  usually  on  account  of  accidental  trauma.  A  very 
satisfactory  operation  for  reconstruction  of  the  upper  lip  is  that  in  which 
flaps  are  taken  on  each  side,  either  extending  upward  with  the  base  downward, 
according  to  the  method  of  Denonvilliers,  or  extending  downward  with  the  base 


FACE    AND    MOUTH 


199 


upward  cU'coi'din^u'  to  the  method  of  Sedillot.  The  method  of  Denouvilliers 
consists  of  two  vertical  tiaps  that  are  made  through  the  full  thickness  of  the 
cheek  with  the  pedicle  below  (Figs.  146  and  147).  The  external  incision  ex- 
tends from  the  lower  border  of  the  jaw  to  the  level  of  the  ala  of  the  nose  and 
the  internal  border  of  the  flap  is  the  margin  of  the  defect  in  the  upper  lip. 
A  transverse  cut  is  made  to  loosen  the  flap,  which  is  turned  down  and  sutured 
in  the  midline  beneath  the  nose.  The  mucous  membrane  lining  the  flaps,  must 
be  arranged  to  form  the  vermilion  border.  The  flap  contains  the  whole  thick- 
ness of  the  cheek.     In  the  operation  of  Sedillot  the  flaps  are  reversed,  taken 


Fig.    148. — Operation   of   Sedillot   for   repair   of  the 
upper  lip. 


Fig.    149. — Lines    of   incision    for   repair    of   defect 
in  upper  lip  by  method  of  Abbe. 


Fig.  ISO. — The  flap  from  the  lower  lip  has 
been  turned  into  the  defect  in  the  upper  lip,  ac- 
cording to  Abbe.  The  flap  is  kept  in  this  position 
for  about  two  weeks,  when  the  pedicle  is  cut. 


Fig.   151. 


-The  pedicle  has  been  cut,  and  the  oper- 
ation   of    Abbe    completed. 


with  the  base  above.  These  flaps  are  turned  upw^ard  and  inward  and  the  ver- 
milion border  is  made  along  the  lower  margins  of  the  flaps  (Fig.  148). 

The  upper  lip  may  be  constructed  from  hair-bearing  tissue  by  taking  a  long 
flap  from  the  temporal  region  which  includes  the  scalp  and  turning  it  down.  A 
similar  flap  is  taken  from  each  side  and  the  pedicle  cut  after  the  local  nutri- 
tion seems  to  make  the  flap  viable. 

In  asymmetrical  deformities  of  the  upper  lip,  the  general  principles  of  plas- 
tic work,  Avhich  have  already  been  discussed,  can  be  applied.  If  there  is  too 
great  contraction  of  the  upper  lip  the  method  of  Abbe  may  be  utilized  and 
a  pedicle  flap  turned  up  from  the  lower  lip.    According  to  this  method,  the  de- 


200 


OPERATIVE    SURGERY 


feet  in  the  upper  lip  is  prepared  and  a  flap  from  the  lower  lip  with  the  pedicle 
on  one  side  (as  shown  in  the  illustrations)  is  turned  up  and  sutured  in  posi- 
tion. The  lips  are  held  together  with  sutures  and  the  patient  is  fed  through 
a  tube  for  twelve  or  fourteen  days,  when  the  pedicle  is  cut.  This  is  a  very 
valuable  method,  particularly  when  the  lower  lip  is  someAvhat  redundant 
(Figs.  149,  150  and  151).  Gurdon  Buck's  operation  involves  the  same  prin- 
ciples, but  a  more  extensive  flap  is  taken,  involving-  probably  a  third  or  even 
half  of  the  lower  lip  and  including  the  angle  of  the  mouth  (Figs.  152  and  153). 
In  any  operation  upon  the  lip,  particularly  upon  the  upper  lip,  it  is  neces- 
sary that  the  internal  surface  have  a  satisfactory  lining,  preferably  of  mucosa. 
If  this  is  not  possible  a  lining  may  be  made  with  skin  by  a  flap  turned  up  from 
the  neck.  If  the  raw  surface  left  within  the  mouth  is  verj^  extensive,  contraction 
is  sure  to  occur  and  so  much  scar  tissue  may  involve  the  flap  that  a  secondary 
operation   will  be   necessary  later.     If  possible,   a   flap   of   mucosa   from   the 


Fig.    152. — Lines   of    incision    for   the    operation    of 
Gurdon    Buck   in   repair   of   the   upper   lip. 


Fig.    153. — Operation    of    Gurdon    Buck    completed. 


tissues  in  the  neighborhood  should  be  utilized  to  line  the  skin  flaps.  Contraction 
Avill  be  less  marked  in  well-established  tissue  from  which  the  mucosa  flap 
is  taken  than  in  the  raw  surface  of  the  new  flap  if  left  unprotected. 

The  lower  lip  may  be  reconstructed  from  flaps  in  its  neighborhood  or  from 
flaps  from  the  arm.  The  lower  lip  is  frequently  the  site  of  cancer  and  recon- 
structions are  often  necessitated  by  operations  for  this  disease.  The  simplest 
method  of  removing  cancer  and  reconstructing  the  lip  after  its  removal  is  by 
the  V-shaped  excision.  If  the  cancer  is  extensive  this  method  cannot  be 
used,  but  in  man}'  early  cases  of  cancer  the  V-shaped  excision  is  entirely 
satisfactory.  Care  is  taken  to  keep  a  safe  distance  from  the  margins  of 
the  cancer.  The  cancer  should  be  cauterized  with  a  thermocautery  just  before 
the  operation,  in  order  to  avoid  the  possibility  of  transplantation  of  cancer  cells. 
The  incision  is  made  so  the  V  will  be  deep  and  not  too  shallow  (Figs.  154  and 
155).  This  results  not  only  in  a  more  extensive  removal  of  tissue,  but  at  the 
same  time  the  closure  of  the  wound  is  more  satisfactorv.    The  incisions  are  made 


FACE    AND    MOUTH 


201 


tlironiih  the  skin  niul  (lowii  lo  Ili(>  imu'osa.  Two  llii-()U,L;li-jiiul-tlirou<;h  sutures 
of  silk\\()nn-<:ul  ;ire  inserted,  one  just  below  tlie  veruiiliou  border  and  one 
farther  down.  The  lo()])s  of  the  suture  are  held  out  of  the  way,  the  mucosa  is 
quickly  cut  and  Ihe  lii)  is  approximated.  In  this  way  not  only  is  bleeding 
lessened,  as  it  can  he  controlled  satisfactorily  hy  the  sutures,  hut  there  is  a 
minimum  exposure  of  the  wounded  surfaces  to  the  secretions  of  the  mouth. 
The  rest  of  the  incision  is  accurately  approximated  with  interrupted  sutures 


Fif 


154. — \'-sIiaiiecl     excision     for    cancer    of    the 
lower   lip. 


Fig.    155. — V-shaped    incision    closed    with    sutures. 


of  arterial  silk  or  horsehair  for  the  skin,  and  arterial  silk  for  the  mucosa.  By 
making  a  transverse  incision  at  each  corner  of  the  mouth,  the  V-shaped  incis- 
ion can  be  applied  in  a  much  larger  number  of  cases  and  this  may  be  com- 
bined with  the  Burow-Stewart  principle  of  excising  a  triangle  of  tissue  down 
to  the  mucosa  just  above  the  angle  of  the  mouth  on  each  side  (Fig.  108).  In 
this  manner  a  considerable  portion  of  the  lower  lip  can  be  removed  with  com- 
paratively little  deformity. 

In  extensive  cancer  of  the  lower  lip  the  operation  of  J.  Clarke  Stewart  is 


■a  ,*^~— ^  —    (,  ^ 


Fig.    156. — Lines    ot    incision    for    operation    of 
Bruns  in  repair  of  lower  lip. 


Fig.   1S7. — Operation    of  Cruns   completed. 


excellent.  The  first  incision  is  just  below  the  jaw  from  one  angle  of  the  lower 
jaw  to  the  other.  The  skin  and  platysma  are  dissected  down  and  a  block  dis- 
section is  made  of  the  upper  neck,  including  both  submaxillary  glands.  This 
dissection  is  made  from  below  upward.  Incisions  are  then  made  on  each  side  of 
the  cancer  at  a  sufficient  distance  from  the  growth  and  are  carried  down  to 
the  original  transverse  incision.  The  lateral  flaps  are  freely  dissected,  from 
the  jaw,  keeping  close  to  the  skin  at  the  lower  part  to  avoid  the  lymphatics. 


202 


OPERATIVE    SURGERY 


The  cancer  and  the  tissues  of  the  block  dissection  of  the  neck  are  removed  in 
one  mass.  If  most  of  the  lower  lip  is  removed  with  the  cancer,  the  mouth  is 
broadened  by  a  straight  incision  outward  from  each  angle  of  the  mouth,  car- 
ried down  to,  but  not  through,  the  mucosa.  A  triangular  incision  is  then  made 
in  the  cheek  just  above  the  angle  of  the  mouth  (Fig.  108).  This  triangular  in- 
cision goes  down  to  the  mucosa,  but  does  not  go  through  it.  The  mucosa  is 
cut  a  half  inch  above  the  level  of  the  lower  lip  and  turned  down  to  make  a  ver- 
milion border.  The  lateral  flaps  are  brought  forward  and  sutured  together  in 
the  midline,  suturing  also  the  new  chin  to  the  soft  tissues  on  the  jaw  to  pro- 
tect the  neck  wound  from  the  contents  of  the  mouth. 

The  lower  lip  may  also  be  reconstructed  by  turning  down  flaps  with  the 


Fig.    158. — Lines    of   incision    for   operation   of 
Estlander   for   repair    of   lower   lip. 


Fig.    159. — Operation    of    Estlander    completed. 


Fig.    160. — Lines   of   incision   for   operation    of 
Dieffenbach  in   repair  of  lower   lip. 


Fig.    161. — Operation    of    Dieffenbach    completed. 


base  below,  the  flaps  so  placed  that  the  incisions  to  close  them  will  lie  in 
the  fold  running  from  the  outer  portion  of  the  ala  of  the  nose  to  the  corner 
of  the  mouth  (Figs.  156  and  157). 

The  operation  of  Abbe  or  of  Gurdon  Buck  for  reconstruction  of  the  upper  lip 
can  be  reversed  for  the  lower  lip  (Figs.  158  and  159).  The  principle  of 
Dieffenbach  which  has  been  referred  to  in  the  chapter  on  plastic  surgery  can 
be  applied  here  in  securing  two  flaps,  one  from  each  side  of  the  defect,  and  bring- 
ing them  together  in  the  midline  (Figs.  160  and  161).  This  leaves  a  triangular 
raw  surface  at  the  outer  portion  of  each  flap,  which  can  be  taken  up  by  sliding 
further  flaps,  by  undermining  and  suturing,  or  by  grafting  skin. 

In  complete  absence  of  the  lip  a  visor  of  skin  may  be  turned  up  from  the 
neck  just  below  the  chin  and  sutured  in  position    (Fig.  162).     This,  however, 


FACE    AND    MOUTH 


203 


is  likely  to  contract,  thoiig'li  this  tendency  may  be  lessened  by  nailing  the  flap 
to  the  jaw  with  small  wire  nails  or  brads  and  holding  it  in  this  position 
until  it  becomes  firmly  fixed.  The  operations  of  Sedillot  may  also  l)e  nscd  in 
some  cases  (Figs.  163,  16-1:  and  165). 

In  extensive  bnrns  when  the  mucosa  of  the  lip  is  not  affected  but  where 
contraction  is  marked  and  scar  tissue  so  abundant  that  no  flap  can  be  secured 


Fig.    162. — Lines   of   incision    for    "visor"    operation   in    repair    of    lower    lip,    according    to    Viguerte-Morgan. 

in  the  neighborhood,  the  method  of  obtaining  a  flap  from  the  arm  offers  a 
solution  of  the  problem.  This  is  the  same  principle  that  is  known  as  the  Italian 
method  of  reconstructing  the  nose.  The  flap  is  best  taken  with  its  base  near  the 
axilla  and  the  incisions  for  it  are  carried  around  the  arm  so  that  the  apex  of 


Fig.   163. — Lines  of   incision   for  operation   of   Sedillot   in   repair  of   the   lower   lip. 

the  flap  lies  in  front  and  a  little  to  the  outer  side  of  the  elbow.  Such  a  flap 
is  well  nourished,  as  it  contains  vessels  that  run  in  the  general  direction  of 
the  blood  supply  of  this  part  and  there  is  very  little  twist  in  the  pedicle.  If 
a  flap  is  taken  with  the  apex  toward  the  axilla  and  base  farther  down  the  arm 
the  nutrition  is  somewhat  imperiled  and  a  larger  raw  surface  of  the  arm  is 
kept  in  contact  with  the  face  than  w^ould  be  with  a  flap  having  its  base 
toward  the  axilla.       The  mouth  is  first  prepared  for  the  reception  of  the 


204 


OPERATIVE    SURGERY 


flap  by  thorough  excision  of  its  scar  tissue  and  the  flap  wliich  will  furnish 
ample  skin  covering  is  dissected  with  some  underlying  fat  and  sutured  in  posi- 
tion by  interrupted  sutures  of  fine  silkworm-gut.  The  raw  surface  of  the 
arm  is  covered  Avith  rubber  protective,  oiled  silk,  or  some  of  the  recent  im- 
pervious transparent  materials  that  are  on  the  market.     The  arm  is  put  over 


Fig.    164. — Lines    of  incision   for  second   method   of 
Sedillot    in    repair    of    the    lower    lip. 


Fig.    165. — Second    metliod    of    Sedillot    completed. 


the  head  after  covering  it  with  a  flannel  bandage  and  is  fastened  in  position  by 
plaster  of  Paris  bandages  which  run  over  the  head.  The  hair  is  protected  by 
a  rubber  cap.     It  is  unnecessary,  as  a  rule,  to  put  plaster  of  Paris  around  the 


Fig.  166. — Methoa  of  securing  a  flap  from  the 
arm  for  repair  of  lower  lip.  Photograph  taken 
just  before   cutting  the  pedicle   of   the  flap. 


Fig.  167. — Ultimate  result  after  repair  of  lower 
lip  following  injury  from  burn  in  the  patient  that 
is  shown  in   Fig.    166. 


neck,  wiiich  makes  dressing  the  w^ound  ditficult  (Figs.  166  and  167).  At  the 
end  of  two  weeks  the  pedicle  is  cut.  The  flap  is  undisturbed  for  about  a  month 
after  the  pedicle  is  cut  and  is  then  refashioned  and  smoothed  to  fit  accurately 


FACE   AND    MOUTH 


205 


willi  tlu'  ;i(l,)(tiiiiiiii'  tissues.  Pai't  iciilar  rare  is  i)ai(l  In  llic  Jiiiictiou  of  the  fiap 
with  the  skill  of  the  t'aet'  in  oihUm-  that  there  may  l)e  no  (h'i)ression  along  the 
line  of  union.  The  |)iMnc'ii)los  for  ])innent ing  this  hax'e  heen  discussed  in  the 
chapter  on  i'laslie  Suri>ery. 

The  nerve  supply  to  these  flaps  in  young  patients  develops  rapidly  and 
within  two  months  from  the  time  the  transplant  has  been  made  sensation  of 
pain  and  touch  in  the  transplanted  flap  becomes  perceptible. 


Fig.   168. — Lines  of   incision   for   operation  of  Montet  in  repair  of  angle  of  the   mouth. 

In  a  lesion  of  the  angle  of  the  mouth  in  which  both  lips  are  affected  the 
operation  of  Montet  is  applicable.  He  uses  two  quadrangular  flaps,  one  from 
the  cheek  and  the  other  from  the  chin  with  the  base  of  each  outward.  The  mar- 
gins of  the  flap,  which  are  to  form  the  edge  of  the  lip,  are  lined  with  mucosa 
(Fig.  168).  If  the  corner  of  the  mouth  is  drawn  uj^ward  it  may  be  corrected  by 
an  operation  of  the  type  of  Sz^-monowski,  in  which  a  triangular  flap  is  made 
with  the  base  downward  and  the  apex  external  to  the  ala  of  the  nose   (Figs. 


Fig.  169. — Lines  of  incision  for  the  operation 
of  Szymonowski  for  repair  of  the  angle  of  the 
mouth. 


Fig.     170. — Operation    of    Szymonowski    completed. 


169  and  170) .  This  flap  is  turned  into  an  incision  just  above  the  mucous  border 
of  the  upper  lip  and  so  lowers  the  outer  angle  of  the  mouth.  The  method  may 
also  be  used  when  the  angle  of  the  mouth  is  depressed.  Here  a  triangular 
flap  is  made  which  includes  the  depressed  angle  of  the  mouth  and  this  is  trans- 
ferred into  a  horizontal  external  cut  in  the  cheek  (Figs.  171  and  172). 

The  vermilion  border  of  the  lip  can  be  restored  by  flaps  of  mucosa  from 
within  the  mouth.  These  are  sometimes  taken  from  the  inner  sides  of  the  up- 
per lip,  turned  down  like  a  visor  after  the  method  of  Schulten  (Figs.  173, 


206 


OPERATIVE    SURGERY 


174  and  175),  or  if  all  of  the  vermilion  border  has  not  been  destroyed  the 
remaining  portion  can  be  dissected  free  as  a  flap  and  stretched  to  cover  the 
defect   (Figs.  176  and  177). 

In  protrusion  of  the  lower  lip,  when  the  mucosa  is  excessive  an  oval  sec- 
tion may  be  taken  from  the  mucosa  near  the  point  where  it  is  reflected  from  the 
inferior  maxillary  bone  and  the  wound  sutured.     This  will  remove  the  redun- 


Fig.    171. — Lines   of    incision   for    correction    of 
downward   contraction   of  the  angle   of  the  mouth. 


Fig.   172. — Completion   of  operation  for  correc- 
tion   of    downward    displacement    of    angle    of    the 

mouth. 


dancy  and  leave  no  external  scar.  Contraction  of  the  mouth  is  dealt  with  on 
the  general  principles  of  plastic  surgery.  Excision  of  the  scar  tissue,  reserv- 
ing the  mucosa  if  it  is  healthy,  is  an  operation  that  can  be  done  in  most  in- 
stances. The  mucosa  is  used  to  form  a  vermilion  border  for  the  newly  con- 
structed lip  (Figs.  178  and  179).  In  severe  burns  both  lips  may  be  fashioned 
from  the  arm,  as  has  already  been  mentioned. 

Defects  of  the  cheek  are  remedied  by  flaps  from  the  neighborhood  when 


Fig.  173. — Lines  of  incision 
foi  operation  of  Schulten  for  re- 
pair   of   mucosa   of   lower   lip. 


Fig.  174. — Section  showing  lo- 
cation of  flap  taken  from  the 
upper    lip. 


*     11      '''^" 


Fig.  175. — The  flap,  according 
to  Schulten,  has  been  sutured 
into  position.  The  pedicles  are 
cut  ten  days  or  two  weeks  later. 


the  defect  is  not  too  great.  It  is  necessary  to  provide  an  internal  lining 
of  either  mucosa  or  skin.  If  the  defect  in  the  cheek  also  includes  a  bony 
defect  in  the  lower  jaw^  a  flap  may  be  turned  up  from  the  neck  contain- 
ing a  section  of  the  clavicle;  or  a  piece  of  rib  may  have  been  previously 
transplanted  beneath  the  skin  of  the  neck  in  such  a  position  that  it  can  be  in- 
cluded in  the  flap  and  turned  into  the  defect.  Great  care  is  taken  during 
the  dissection  to  prevent  dislodging  the  attachments  of  the  bone  graft  or 


FACE    AND    MOUTH 


207 


the  section  of  (.'lavicle.  AVlu'ii  llic  clavicle  is  used  it  is  sawed  to  the  depth 
of  about  oiu>-t'()urth  of  an  incli  on  each  side  of  the  flap  before  the  flap  has 
been  completely  dissected  free,  and  the  bone  is  severed  from  the  clavicle  by  a 
sharp  chisel  or  fine  saw.  Holes  are  drilled  in  the  two  ends  of  the  bone  from  the 
clavicle  before  it  has  been  severed,  protecting  the  under  surface  of  the  clavicle  by 
a  retractor  slipped  behind  it  to  avoid  injury  to  the  deeper  tissues  if  the  drill 
should  perforate  the  clavicle  (Figs.  180,  181  and  182).  It  is  best  to  keep  the  bone 


Fig.  176. — Lines  of  incision  for  repair  of  mu- 
cosa of  lower  lip  according  to  the  method  of 
Nelaton  and  Ombredanne. 


177. — Operation  of  Nelaton  and   Ombredanne 
completed. 


firmly  fixed  to  the  flap  by  clamps  until  it  has  been  secured  in  the  defect.  It 
is  fastened  to  the  edges  of  the  defect  in  the  jaw  bone  with  kangaroo  tendon 
passed  through  drill  holes.  The  skin  flap  is  sufficiently  long  to  turn  over  and 
protect  the  bone  from  the  mouth. 

Defects  of  the  cheek  that  cannot  be  corrected  by  sliding  flaps  from  the 
neighborhood  may  be  repaired  by  turning  flaps  up  from  the  neck  or  by  secur- 
ing flaps  from  the  arm,  or  from  the  forehead.  If  flaps  are  taken  from  the  neck 
they  will  necessarily  be  long  and  should  be  lined  by  mucosa  or  else  doubled 


Fig.  178. — L,ines  of  incision  for  reconstruction 
of  vermilion  border  of  the  lower  lip.  Tissues 
from  "A"  to  "B"  should  be  excised  and  the  flap 
indicated  by  the  lines  of  incision  pulled  down. 
This   is   the    operation   of   Tripier. 


Fig.  179. — The  vermilion  border  of  the  lower 
lip  reconstructed  according  to  the  method  of  Tri- 
pier. 


over  so  as  to  have  an  epithelial  lining  on  each  side,  or  if  this  is  impossible 
a  flap  may  be  turned  into  the  mouth  with  the  skin  side  inward  and  another 
flap  used  to  cover  the  raw  surface.  If  a  flap  from  the  neck  is  used,  it  being  long 
and  in.  the  reversed  direction  of  the  blood  supply,  gangrene  may  occur.  It  is 
best  to  separate  the  flap  except  at  its  extremities,  as  has  been  mentioned 
in  the  chapter  on  Plastic  Surgery,  "tube"  the  pedicle,  and  then  gradually  di- 
vide the  end  opposite  the  pedicle.     This  procedure  may  take  several  weeks, 


208 


OPERATIVE    SURGERY 


but  it  will  greatly  develop  the  blood  supply  and  will  lessen  the  possibilities  ol' 
sloughing.  The  flap  can  then  be  doubled  on  itself  before  being  transplanted,  so 
that  it  will  be  abundantly  nourished  when  it  is  finally  fit  into  the  cheek  (Figs. 
183  and  184). 


■  Fig.  ISO.^Reconstruction  of  defect  in  the  lower  jaw  by  a  pedicle  flap  including  a  portion  of  the 
clavicle.  The  flap  is  long  enough  to  reach  over  the  section  of  clavicle  into  the  mouth  and  completely  en- 
velopes the  bone. 


Fig.  181. — I^ines  of  incision  for  repair  of  defect 
in  the  midline  of  lov.'^r  jaw.  A  piece  of  rib  has 
been  previously  grafted  under  the  skin  of  the  flap. 


Fig.  182. — The  flap  with  its  grafted  bone  is 
turned  into  the  di^fect  of  the  lower  jaw.  The 
skin  is  long  enough  to  fold  over  the  grafted  bone. 


In  defects  in  the  upper  part  of  the  cheek  in  which  there  is  no  need  for 
mucous  lining,  I  have  turned  doAvn  a  flap  from  the  forehead  using  the  an- 
terior temporal  artery  as  the  pedicle.  The  defect  is  prepared  and  a  flap  of 
proper  size  is  outlined  on  the  forehead  in  such  a  way  that  it  is  supplied  by  the 


FACE    AND    MOTTTII 


209 


anterior  temporal  artery,  wliieli  is  disseeted  out  aloii^'  willi  any  adjoin in<^'  veins 
and  some  surroundin<i'  eonneetive  tissue.  An  ineision  is  made  in  the  skin, 
merely  g'oinj^-  thr(ni<i'li  the  skin  hut  Jiot  deep  enough  to  injure  the  branches  of 
the  facial  nerve.  The  skin  is  undermined  on  each  side  of  the  incision  so  the 
transplanted  artery  can  be  covered  without  tension.  The  artery  is  placed  in 
this  incision  and  the  flap  sutured  to  the  surrounding  raw  surface.  The  chief 
danger  in  this  operation  is  from  too  much  blood  supply.  The  flap  should  be 
punctured  at  several  points  so  the  excessive  amount  of  venous  blood  can  be 
drained  off  and  it  is  well  not  to  apply  the  sutures  too  closely,  in  order  to  af- 
ford exit  of  venous  blood  between  the  stitches.  If  the  flaj)  becomes  purplish 
during  tlie  first  two  days  a  sharp-pointed  knife  should  be  inserted  between  the 


Fig.  183. — Lines  of  incision  for  repair  of  de- 
fect in  the  cheek  and  angle  of  the  mouth.  The 
flap  is  so  fashioned  that  tip  "A"  is  folded  over 
the   rest  of  the  flap   and  turned   into   the   mouth. 


Fig.    184. — Tre    flap    indicated    in    the    previous 
figure  has  been  dissected  and  placed  in  the  defect. 


stitches  at  several  points  and  the  margin  of  the  flap  scraped.  This  procedure 
together  with  a  few  stab  wounds  may  tide  over  the  danger  of  too  much  venous 
congestion,  which  occurs  in  the  first  few  days.  I  was  unaware  at  the  time  I 
described  this  operation  that  Monks,  of  Boston,  had  already  employed  this 
principle  in  reconstructing  the  eyelid.  Blair  has  suggested  a  modification  for 
defects  lower  in  the  cheek  so  that  the  flap  could  be  turned  with  the  skin  surface 
within  the  mouth  and  the  raw  surface  externally.  Later  the  raw  surface  can 
be  covered  by  Thiersch's  grafts  or  by  flaps  from  the  neck.  I  had  previously 
lined  the  buccal  surface  of  this  flap  by  a  skin  flap  from  the  neck,  but  Blair's  sug- 
gestion will  secure  a  more  stable  lining  for  the  mouth,  though  the  raw  surface 
wall  have  no  opposing  raw  surface  with  which  the  veins  of  this  flap  may  be- 
come promptly  connected  to  relieve  the  venous  congestion. 


210  OPERATIVE    SURGERY 

A  flap  from  the  forehead  may  be  turned  down  with  the  pedicle  in  the 
temporal  region  and  the  pedicle  cut  after  the  flap  has  taken.  This  is  really  a 
much  better  procedure  than  transpl anting'  tlie  temporal  artery,  for  the  local 
blood  supply  of  the  flap  may  be  developed  by  compressing  the  pedicle  one  or 
two  hours  a  day  after  the  first  week,  as  described  in  the  chapter  on  Plastic 
Surgery,  or  the  pedicle  can  be  severed  in  successive  stages.  The  great  objec- 
tion to  transplantation  of  the  temporal  artery  alone  is  that  it  does  not  pro- 
vide a  venous  return  circulation  as  does  a  pedicle  of  skin  and  subcutaneous  tis- 
sue. 

Willard  Bartlett  suggests  covering  the  buccal  surface  of  a  flap  transplanted 
into  the  cheek,  by  turning  up  a  flap  of  mucosa  along  with  some  of  the  tongue. 
The  tongue  is  cut  loose  later.  In  such  an  instance  it  is  necessary  to  remove 
the  teeth  or  at  least  to  protect  the  mucosa  of  the  transplanted  tongue  until  its 
pedicle  is  cut. 

THE  EYELIDS 

Operations  on  the  eyelids  are  usually  for  the  purpose  of  excising  neoplasms 
or  for  deformity  caused  by  trauma,  ulcer,  burns  or  the  removal  of  neoplasms. 
Occasionally  the  eyelids  turn  in,  entropion,  and  the  operation  for  this  consists 
in  excision  of  tissue  from  the  external  surface  of  the  upper  and  lower  eyelids. 
The  excision  includes  not  only  the  skin  but  the  fibers  of  the  orbicularis  muscle 
with  some  of  the  thickened  tarsal  cartilage.  The  excision  is  made  in  such  a  manner 
as  not  to  disturb  the  margins  of  the  lid. 

The  most  common  lesion  of  the  eyelid  is  eversion,  or  ectropion.  If  the 
contraction  which  caused  ectropion  were  located  in  one  spot  or  confined  to  one 
line,  the  operation  for  the  correction  of  this  condition  would  be  comparatively  sim- 
ple. Unfortunately,  however,  the  surrounding  tissues  to  a  considerable  extent 
are  usually  affected  by  the  scar  tissue  and  it  is  often  difficult  to  secure  a  suffi- 
cient amount  of  normal  skin  to  give  satisfactory  support  to  the  eyelid. 

The  types  of  operations  that  are  applicable  may  be  divided  into,  (1)  skin 
grafting,  with  free  grafts,  (2)  sliding  flaps  or  pedunculated  flaps  from 
the  adjacent  tissue,  and  (3)  pedunculated  flaps  from  a  distant  part.  These 
types  of  operations  are  suitable  for  either  ectropion  or  reconstruction  of  the 
lids.  The  only  difference  is  that  in  reconstruction  of  the  lids,  w^here  the  con- 
junctiva and  the  tarsal  cartilages  are  absent,  it  is  essential  to  have  the  inner 
raw  surface  of  the  graft  covered  with  epithelium.  To  accomplish  this  a  Thiersch 
graft  is  placed  on  the  flap  before  it  is  shaped  into  an  eyelid. 

Skin  grafting  for  eversion  of  the  upper  or  lower  lids  is  not  satisfactory 
as  a  rule  unless_  whole  skin  grafts  are  used.  If  the  eversion  is  due  to  contrac- 
tion of  a  scar,  and  the  scar  is  excised  and  a  Thiersch  graft  applied,  a  re- 
currence of  the  contraction  may  be  looked  for  unless  the  scar  is  very  super- 
ficial. In  order,  then,  to  correct  contraction  in  a  deep  injury  of  the  eyelid  it 
is  necessarj^  to  transplant  whole  skin.  AVhen  the  operation  is  for  ectro- 
pion where  the  tarsal  cartilage  and  the  conjunctiva  are  well  preserved  the 
whole  skin  graft  usually  gives  excellent   results.     It  was  for  this  type   of 


FACE    AND    MOUTH 


211 


rig.    185. — Line    of    incision    for    releasing    con-         Fig.    186. — Dissection   of   contraction   of   upper   lid. 
traction  of  the  upper  lid  according  to  operation   of 
Gillies. 


Fig.  187. — The  upper  lid  is  freed  and  turned  down. 


Fig.    188. — Thiersch   graft   is   placed   on   a   mold    of 
wax.      (Gillies.) 


U.L.U 


Fig.  189. — The  mold,  with  the  Thiersch  graft 
placed  with  the  epithelium  next  to  the  mold,  is 
sutured  into  the  raw  surface  left  by  dissecting 
the  contractions  of  the  upper  lid.     (Gillies.) 


Fig.  190. — The  sutures  which  catch  the  skin  of 
the  lids  and  the  graft  are  tied.  The  sutures  and 
mold  are  removed  in  about  ten  days.     (Gillies.) 


212 


OPERATIVE   SURGERY 


operation  that  the  Avhole  skin  graft  of  Wolfe  was  originally  devised.  If 
there  is  considerable  infection  abont  the  eye,  which  cannot  be  cleared  up, 
the    graft    may    not    l)e    successful.      The    tcehiiic    of    its    application    is    the 


S^^Sril.'    1 

{./>-. 

^_.--j^*-         -  ■  - 

"'■^■(t 

m 

..^,-..:'^*^ 

H-LL. 

Fig.   191. — The  late  result  of  operation  of  Gillies   for  eversion   of  upper  lid. 


Fig.    192. — I^ines    of    incision    for    the    Wharton 
Jones  operation  for  ectropion  of  the   lower  lid. 


Fig.     193. — The    operation    of    Wharton    Jones 
completed. 


Fig.    194. — Lines    of   incision   for    operation    of 
Dieifenbach   for   ectropion    of  lower   lid. 


Fig.    195. — Operation    of    Dieffenl.ach    completed. 


same  as  has  been  described  in  the  chapter  on  Plastic  Surgery.  In  order  to 
prevent  infection  from  the  secretions  of  the  eye,  it  is  necessary  to  keep  the  graft 
covered  with  moist  saline  gauze,  which  should  be  changed  several  times  a  day. 


FACE    AND    MOUTH 


213 


Gillies'  iiiuls  that  wlieii  the  saw  contraction  oi'  a  lid  is  very  superficial 
and  all  of  the  eorinni  has  not  been  destroyed,  the  nse  of  Thiersch  <>'rarts  may 
be  siiecessful.  The  eyelid  is  mobilized  and  the  scar  dissected  away  (Figs.  185, 
186,  and  187),  then  the  graft  is  applied  to  a  mold  of  dental  wax  made  to 


.;;yf 



-"-"'!  -wi^t''r 

_-^ 

_  ^L-^:-^^-^"  ^ 

Ul  L. 

Fig.    19(1. — Lines    of    inci.sion    for    oiiciation    of 
Knapp   for   repair  of  lower   lid. 


Fig.     197. — Operation    of    Knapp    completed. 


Fig.  198. — Operation  of  Monks  for  repair  of 
lower  lid.  A  flap  is  dissected  from  the  forehead 
witli   the   temporal   artery   as   pedicle. 


Fig.  199. — The  flap  is  freed  and  caught  with 
forceps,  to  be  drawn,  through  a  tunnel  from  the 
lower  lid  to  the  temporal  artery. 


Fig.   200. — The   operation   of   Monks   completed. 

fit  the  defect,  with  the  raw  surface  of  the  graft  external  (Fig.  188).  The 
mold  covered  with  the  graft  is  fastened  in  the  defect  with  sutures  which  catch 
the  margins  of  the  graft  (Figs.  189  and  190).  The  sutures  and  the  mold  are 
removed  in  a  week  or  ten  days  (Fig.  191). 


^Surg.,  Gynec.  &  Obst.,  February,   1920,  p.  133. 


214  OPERATIVE    SURGERY 

In  all  operations  upon  the  eyelid  the  lids  are  sewed  together  after  trimming 
the  eyelashes,  or  a  better  plan  still  is  to  overcorrect  the  lids  by  overlapping 
them.  If,  for  instance,  the  lower  lid  is  to  be  operated  upon,  it  may  be  folded 
over  the  upper  and  the  sutures  in  its  edge  are  fastened  to  the  forehead  hj 
adhesive  plaster.  This  method  has  been  made  use  of  by  a  number  of  sur- 
geons to  obtain  overcorrection  while  the  lid  is  healing.  It  is  highly  essential 
to  overcorrect  the  lid  in  any  plastic  operation,  because  there  is  a  tendency  to 
contraction. 

If  the  whole  skin  graft  cannot  be  used  satisfactorily,  the  method  of  sliding 
flaps  from  the  neighborhood  must  be  considered.  The  operation  to  be  selected  de- 
pends to  a  large  extent  upon  the  character  of  the  contraction.  If  the  contrac- 
tion is  linear  or  very  limited  the  operation  of  Wharton  Jones  is  excellent. 
Here  a  V-shaped  incision  is  made,  beginning  at  each  extremity  of  the  lower 
eyelid  and  uniting  at  an  acute  angle  some  distance  below  the  lid.  If  the  con- 
tracting band  is  in  the  midline  or  near  a  line  of  the  incision  it  is  thoroughly 
excised.  The  skin  is  well  undermined  along  the  margins  of  the  incision  and 
the  wound  is  sutured,  converting  the  V-shaped  incision  into  a  Y  and  so  push- 
ing up  the  lower  lid  (Figs.  192  and  193).  The  method  of  Dieffenbach  can  also 
be  used.  This  consists  in  taking  a  quadrangular  flap  whose  upper  end  is  about 
on  the  level  of  the  normal  upper  border  of  the  lower  lid  when  the  eye  is  closed, 
but  external  to  the  outer  canthus  of  the  eye.  The  base  is  below  and  inward. 
After  excising  the  scar  tissue  or  the  growth  below  the  eyelid,  this  flap  is  slid 
inward  to  replace  the  excised  area  and  the  triangular  denuded  area  left  by 
the  graft  is  partly  sutured  and  partly  covered  by  a  Thiersch  graft  (Figs. 
194  and  195).  A  flap  can  also  be  taken  with  its  base  near  the  outer  canthus 
and  extending  either  downward  or  upward,  or  with  its  base  near  the  inner 
canthus  and  extending  downward.  This  flap  may  be  turned  into  the  raw  surface 
left  by  excision  of  the  scar  tissue  of  the  lower  lid.  The  general  principles  of 
plastic  operations  as  described  under  Plastic  Surgery  are  followed  here.  A 
quadrangular  flap  may  be  slid  according  to  the  method  of  Knapp  on  a  horizon- 
tal plane  with  the  defect  caused  by  excising  the  scar  tissue  of  the  lower  lid 
(Figs.  196  and  197).  If  the  deformity  is  confined  to  the  lower  lid  and  there 
is  a  redundancy  of  tissue  in  the  upper  lid  a  flap  of  skin  may  be  turned  down, 
visor-like,  from  the  upper  lid  to  the  lower  lid.  Here  a  strip  of  skin  is  cut 
from  the  upper  lid  by  two  parallel  incisions,  which  form  a  bridge  of  tissue 
attached  at  its  two  ends,  one  above  the  outer  and  one  above  the  inner  canthus 
of  the  eye.  This  bridge  is  turned  down  according  to  the  method  of  Landolt 
to  the  lower  lid  and  sutured  in  position. 

The  method. of  Monks  consists  in  outlining  the  eyelid  on  the  forehead  and 
dissecting  out  a  pedicle  containing  the  anterior  branch  of  the  temporal  artery 
and  vein  with  some  surrounding  connective  tissue.  This  flap  is  carried  under 
a  tunnel  burrowed  from  the  lower  end  of  the  incision,  so  the  anterior  temporal 
artery  nourishes  the  reconstructed  lower  lid  (Figs.  198,  199  and  200).  As 
described  on  p.  209  I  used  the  same  principle  in  supplying  a  flap  from  the 
forehead  for  defects  of  the  cheek.    At  the  time  I  reported  this  I  was  unaware 


PACE    AND    MOUTH 


215 


tig.  201. — Operation  of  Gibson  for  repair  of 
lower  lid.  A  pocket  is  made  for  tlie  reception  of 
Thiersch  graft. 


Fig.    202. — Thiersch    graft    is   placed    in   position. 


Fig.  203. — The  growth  on  the  lower  lid  is  excised. 


Fig.  204. — Ten  days  after  the  grafting  the  flap 
is  dissected  according  to  the  method  of  Gibson 
and   drawn   over  the   defect  in   the   lower   lid. 


Fig.    205. — The    operation    of   Gibson   completed, 


216 


OPERATIVE    SURGERY 


Fig.  206. — Lines  of  incision  for  operation  of  Sj'ndacker-Morax  for  repair  of  both  lids. 


Fig.  207. — The  pedicle  has  been  sutured  into  position  to  the  upper  lid.     Ten   days   later   (A)    the  pedicle  is 
cut  and  the  lower  portion  of  the  flap  turned  into   the   defect  of  the   lower   lid. 


FACE   AND    MOUTH 


217 


of  tlie  oi^eration  of  ]\Ioiiks  and  iiiicoiisciously  used  the  principle  tliat  he  had 
established  several  years  iirevionsly.  On  aeeount  of  defective  venous  circula- 
tion I  have  found  this  principle  unsatisfactory  in  laroer  flaps. 

Gibson  uses  a  (|uadrilateral  flap  wliieh  is  best  explained  by  the  accompanying- 


Fig.  20S. — Deformity  following  a  burn  in  a 
boy,  J.  M.  Note  marked  eversion  of  both  lids,  par- 
ticularly on  the   right  side. 


Fig  209— 11k  lali.m  -li  '  11  I  u'  208.  The 
mouth  has  been  lepaued  by  pedieled  flap  from  his 
arm.  Both  hds  of  the  right  eye  have  been  freed, 
sutured  together,  and  covered  with  a  pedicled  flap 
from  the  forearm,  which  was  left  in  position  about 
two    weeks   before   the   pedicle   was   cut. 


Fig.   210. — Patient   shown   in   Fig.    209.     The   flap    which   covered   both    lids   of   the    right   eye   has   been   split. 
The  patient  is  shown  with  his  eyes  closed  as  tightly  as  possible  to   demonstrate   lack   of   eversion. 


illustration  (Fig.  201).  A  horizontal  incision  is  made  from  the  outer  eantlius  of 
the  eye  aud  a  Thiersch  graft  tucked  iu  (Fig.  202).  This  tissue  is  shaped  into  a 
quadrangular  flap  after  the  graft  has  taken  and  is  slid  inward  to  supply  the  defect 


218 


OPERATIVE    SURGERY 


in  the  lower  lid  (Figs.  203,  204  and  205).  Only  the  outer  half  of  the  lower 
lid  can  be  reconstructed  by  this  method.  For  the  inner  side  of  the  lid  a  flap 
may  be  taken  from  the  bridge  of  the  nose  and  turned  down. 

It  must  constantly  be  borne  in  mind  that  if  the  operation  is  for  recon- 
struction of  the  lower  lid,  and  not  for  correcting  eversion,  whole  skin  grafts 
cannot  be  used,  for  it  is  necessary  to  cover  the  raw  surface  next  the  eye  with 
a  Thiersch  graft.     This  should  be  dene  on  a  flap  two  weeks  before  the  flap  is 


Fig.   211. — Excision   of  V-shaped   section   of  lower  lid   for   senile   ectropion.     Operation   of  von   Ammon. 


Fig.    212.— Lengthening    the    outer    canthus    of    the         Fig.  213.— Narrowing  the  outer  canthus  of  the  eye 
eye  according  to  von  Ammon-Agnew.  according  to  Walthers. 

turned  into  its  position.  On  account  of  the  secretions  of  the  eye  it  is  difficult  or 
impossible  to  graft  the  flap  after  it  is  in  permanent  position  and  if  it  is  not 
thus  covered  contraction  of  the  raw  surface  will  interfere  with  the  success  of  the 
operation. 

Flaps  from  a  distance  are  obtained  from  the  neck  or  from  the  arm.  If 
from  the  neck,  a  long  narrow  flap  is  cut  according  to  the  method  of  Syndaeker- 
Morax,  with  the  base  about  the  mastoid  region  and  the  tip  of  the  flap  over  the 


PACE   AND    MOUTH 


219 


sternoelaviciilar  articulation  (Figs.  206  and  207).  As  sneli  a  flap  is  long  and 
narrow  it  would  be  safer  to  utilize  the  principle  mentioned  in  the  chapter  on 
Plastic  Surgery  and  first  make  a  bridge  of  the  tissue  for  the  flap,  "tube"  the 
pedicle,  and  gradually  cut  the  distal  end  so  as  firmly  to  establish  the  circula- 
tion. 

A  pedicle  flap  from  the  arm  may  be  obtained  for  the  eyelids.  It  should 
be  from  the  inner  surface  of  the  arm  or  from  the  inner  surface  of  the  forearm. 
Skin  from  these  regions  matches  well  with  the  eyelids  and  should  be  used 
when  the  whole  skin  graft  is  indicated.  A  pedicle  flap  from  this  region  is 
taken  with  a  broad  base  and  with  a  flap  large  enough  to  have  an  abundance  of 
tissue.  The  eyelids  are  denuded  by  dissecting  away  the  connective  tissue  thor- 
oughly and  sewing  the  lids  together.  If  only  the  lower  lid  is  everted  a  flap  is 
sewed  in  this  position,  but  if  both  lids  are  affected  a  large  flap  is  made  to  cover 


Fig.  214. — Reconstruction  of  the  eyebrow  by  turn- 
ing down  a  flap  from  the  forehead. 


Fig.  215. — Reconstruction  of  the  eyebrow  by  turn- 
ing down  a  flap  from  the  temporal   region. 


both  lids  (Figs.  208,  209  and  210).  The  pedicle  is  severed  in  about  two  weeks, 
after  compression  for  an  hour  at  a  time  for  five  days,  and  a  week  later  the 
flap  is  split  to  make  both  upper  and  lower  lids.  The  accompanying  photo- 
graph shows  this  method  after  the  pedicle  has  been  cut  and  before  the 
flap  has  been  split  to  form  the  eyelids. 

In  eversion  of  the  eyelids  which  has  existed  for  a  long  time,  either  as  a 
result  of  cicatricial  contraction  or  because  of  a  paresis  of  the  tissues  as  in 
senile  ectropion,  a  V-shaped  section  of  the  lid  should  be  removed.  This  in- 
cludes the  conjunctiva  and  the  tarsal  cartilage,  as  well  as  the  skin.  The  wound 
is  sutured  carefully  with  fine  sutures  of  arterial  silk,  bringing  the  tissues  into 
accurate  approximation  (Fig.  211).  At  the  margin  of  the  lid  where  there 
is  the  greatest  strain  it  is  wise  to  insert  a  somewhat  stouter  silk  suture.  This 
may  be  all  that  is  necessary  for  atonic  ectropion,  but  in  ectropion  from  scar 
tissue  contraction,  it  is  only  one  step  of  the  operation  and  should  be  followed 
by  either  a  whole  skin  graft  or  a  flap  operation. 

Deformities  that  involve  shortening  or  lengthening  the  palpebral  opening 
can  easily  be  corrected  along  the  principles  of  plastic  surgery.     If  the  opening 


220 


OPERATIVE    SURGERY 


is  to  be  lengthened,  the  onter  eantlius  is  split  or  a  triangular  area  excised 
and  the  conjunctiva  is  sutured  to  the  skin  (Fig.  212).  In  shortening  the  pal- 
pebral tissue,  a  triangular  area  including  the  outer  canthus,  is  denuded  and 
sutured  as  a  straight  line  (Fig.  213). 

In  reconstruction  of  the  eyebrows  whole  skin  grafts  may  be  used,  taking 
the  skin  from  some  hairy  region  of  the  body  as  the  pubes  and  transplanting 


Fig.    216. — Painful   and    contracted    scar   left    after    removal    of   an    eye.      (J.    S.    Davis.) 


,'fl'.'''' 


u 


Fig.   217. — A  flap   dissected   from   the   abdomen   according  to   the   method    of  J.    S.    Davis. 

it  according  to  the  technic  of  whole  skin  grafting,  which  has  been  described. 
A  pedicle  flap  can  be  used  by  turning  down  a  flap  from  the  scalp  (Fig.  214) 
with  its  base  in  the  temporal  region  (Fig.  215),  or,  if  the  defect  only  involves 
one  eyebrow  and  the  other  eyebrow  is  well  developed,  this  eyebrow  can  be  split 
to  form  a  flap  with  its  base  on  the  bridge  of  the  nose  and  the  flap  containing  half 


PACE    AND    MOUTH 


221 


an  eyebrow  luriiccl  over  to  the  r(\uioii  oi'  the  defect.     A  liairy  flap  should  be 
shaved  before  it  is  transplanted. 

After  extensive  operations  for  cancer  of  the  lids,  involving  the  eye- 
ball, it  is  sometimes  difficult  to  close  the  socket  of  the  orbital  cavity.  The 
bone  furnishes  scant  nutrition   for  the  scar  and  frequentl}'  the  contraction  and 


Fig.  218. — The  abdominal  flap   has  been  sewed  to  the  incision  in  the  hand,   and  two  weeks   later   the  pedicle 
of  the  flap  is   cut  and  the  hand  transferred  to  the  region  of  the   eye.      (Davis.) 


Fig.   219. — The  painful   scar  in  the  eye   socket   has  been   removed   and   the   flap   on   the  hand   sutured  in   posi- 
tion.    Ten   days  later   its   connection  with  the   hand   is   divided.      {] .    S.   Davis.) 


222 


OPERATIVE    SURGERY 


pulling  on  the  surrounding  tissue  cause  great  deformity  and  pain  (Fig.  216). 
After  denuding  the  cavity  a  flap  from  the  forehead  may  be  turned  into  this  de- 
feet,  or  the  operation  of  J.  S.  Davis  may  be  done.  A  flap  of  skin  with  a  thick 
pad  of  fat  from  the  abdomen  (Fig.  217)  is  sutured  into  an  incision  in  the 
palm  of  the  hand.  After  about  twelve  days  the  attachment  of  this  flap  to 
the  abdomen  is  severed  and  the  hand  containing  the  flap  (Fig.  218)  is  trans- 
ferred to  the  region  of  the  eye  where  the  flap  is  sutured  in  position.  "When  its 
nutrition  has  been  established  in  its  new  location  its  connection  with  the  palm 
of  the  hand  is  severed  (Fig.  219). 

EARS 

Deformities  of  the  ear  which  consist  of  congenital  enlargement  or  mal- 
position of  the  ear  are  comparatively  easily  corrected,  but  the  construction 
of  an  ear  when  it  is  congenitally  absent  or  when  it  has  been  removed  by  trauma 
is  a  very  difficult  and  unsatisfactory  procedure.     Ears  that  stand  out  from 


\ 

r- 

^         v/ 

ST- 

•   1         ^    ~ — 

^ 

cf>  ^^ 

/ 

,-^          \ 

/ 

--'1 

Fig.  220. — The  operation  of  Monks  for  prominent  ears. 


Fig.     221. — Operation    of     Luckett     for    prominent  Fig.   122. — Method   of   reconstructing   ears  that  are 

ears.  too  large. 


PACE   AND    MOUTH 


223 


tlie  liead  in  iimisujil  iiroiniiiaiiee  ave  reduced  by  the  operation  of  Monks,  in 
wliieli  an  elli]-)se  of  skin  and  snI)eutaneons  tissue  is  removed  from  the  back 
of  tlie  ear,  and  the  skin  ed.ucs  of  tlie  wound  are  sutured  togetlu'r  (Fi<^'.  220).     If 


c/ 


\'' 


y^y 


Fig.    223. — Lines    of   incision    for   the    operation    of 
Szymonowski  for   reconstruction   of  the   ear. 


Fig.   224. — The   flap   is   dissected   up   and   folded   on 
itself. 


Fig.  225. — Lines  of  incision  at  "A"  and  "B"   shov 
outlines    of    flap. 


Fig.  226. — Flaps  "A"  and  "B"  are  raised  and 
the  extremities  of  the  new  ear  are  brought  for- 
ward. 


Fig.  227. — The  flaps  "\"   and  "B"  are  transferred  posteriorly. 


the  deformity  is  more  extensive  and  the  ears  are  large  the  operation  of  Luekett 
is  more  satisfactory.  Here  incisions  are  made  in  the  posterior  surface  of  the 
ear  to  remove  a  crescentic  area  of  skin,  and  also  a  similar  area  of  cartilage  after 
undercutting  the  skin.     Care  is  taken  not  to  carry  the  incision  through  the 


224 


OPERATIVE    ST'RGERY 


ear,  so  there  will  be  no  scar  visible  on  the  anterior  surface  of  the  ear.  The  carti- 
lage is  sutured  with  interrupted  sutures  of  catgut  inserted  somewhat  like  the 
Lembert  intestinal  sutures,  turning  the  edges  of  the  cartilage  forward  to  form 
a  ridge,  which  is  usually  absent  in  these  large  ears  (Fig.  221).  When  the 
ear  is  unduly  large  it  can  be  reduced  by  excision  of  a  triangular  area,  which 
may  be  accompanied  by  excision  of  smaller  triangles  in  order  to  reduce  the 
size  of  the  ear  not  only  from  above  down''  ircl  but  from  before  backward  (Fig. 
222).  The  size  of  the  lobule  of  the  e.  can  be  lessened  by  excision  of  a 
triangular  area. 


Fig.  228. — Lines  of  incision 
for  operation  of  Roberts  for  re- 
constructing   the    ear. 


Fig.  229. — Tlie  flap  is  dis- 
sected up  and  folded  upon  itself. 
Lines  of  incision  for  construc- 
tion of  lobe  of  the  ear  are 
shown. 


Fig.  230. — The  lobe  for  the 
ear  is  dissected  up  and  attached 
to  the  body  of  the  ear. 


Complete  reconstruction  of  an  ear  is  difficult  and  unsatisfactory.  The  op- 
eration of  Szymanowski  has  had  considerable  vogue.  The  incisions  are  made 
according  to  the  illustration  (Figs.  223,  224,  225,  226  and  227).  If  the  hair 
is  too  abundant  in  this  region  the  operation  of  Roberts  may  be  used  (Figs. 
228,  229  and  230).  Here  a  flap  is  raised,  as  shown  in  the  illustrations,  and  the 
posterior  part  is  folded  back  to  give  thickness  and  a  rim  for  the  ear.  After 
this  has  taken,  an  independent  flap  is  formed  lower  down  to  construct  the 
lobule  and  is  connected  with  the  original  flap. 


THE  EXTERNAL  NOSE 

Operations  on  the  nose,  like  the  surgery  of  other  prominent  portions  of  the 
face,  consist  largely  of  plastic  operations,  intended  to  correct  defects,  either 
congenital  or  resulting  from  disease  or  trauma.  An  occasional  type  of  de- 
formity is  that  which  unfortunately  folloAvs  the  use  of  a  paste  in  removal 
of  malignant  growths  from  the  nose.  These  cancers  can  be  removed  much 
better  and  with  less  pain  and  resulting  deformity  by  the  electric  cautery,  but 
the  superstitious  dread  of  an  operation  wdll  often  cause  a  patient  to  suffer 
great  agony  and  the  conspicuous  deformity  which  results  from  the  paste  rather 
than  have  the  simpler,  more  effective,  and  less  deforming  operation. 


FACE    AND    MOUTH 


225 


Occasionally  llicrr  is  a  marked  liypci'l  I'opliy  of  llic  skin  of  Hie  nose  result- 
ing froiii  acne.  'Phis  hypertrophy,  wliieh  is  leriiied  rhinophyma,  is  best  reinox'ed 
by  excision  of  the  skin  down  lo  the  cai'tilasie.  The  finger  is  placed  in  the  nosti'il 
to  previ'iit  injury  to  the  carlilai^e  and  a  clean  excision  is  done.  It  is  best  to 
split  the  growth  in  the  middle  and  remove  it  in  two  halves  so  that  the  outline 
of  the  cartilage  can  be  readily  distinguished,  each  half  being  dissected  from 
the  middle  line.    The  raw  surface  is  then  grafted. 

In  repair  of  small  or  partial  defects  of  the  ala  of  the  nose,  without  ex- 
tensive sear  tissue  in  the  neighborhood,  flaps  can  be  taken  from  the  skin  in 
the  region  of  the  ala.  If  the  defect  consists  of  partial  destruction  of  the 
ala  with  the  edge  of  the  ala  drawn  high  up,  it  is  best  to  take  a  flap  from 
the  margin  of  the   defect  after  making  an  incision  to  lower  the   ala.     This 


Fig.   231. 


Fi.a:. 


Fig.   231. — Lines   of   incision   for   operation   of    Dsmarch   for  reconstruction   of   ala   of   nose. 
Fig.    232. — The  pedicled   flap   is   turned   into   position.     Ten    days   later   the   pedicle   is   severed. 
Fig.  233. — Operation  of  Fsmarch  completed. 


Fig.    234. 


Fig.   235.- 


Fig.   234. — Lines  of  incision   for   operation   of   Dieffenbach   for   defect   of   ala   of   nose. 
Fig.   235. — Operation  of  Dieftenbach   completed. 

can  be  done  by  the  operation  of  Esmarch,  in  which  a  flap  is  taken  from 
the  nasolabial  fold  and  turned  up  into  either  the  defective  ala  (Figs.  231, 
232  and  233),  or  better  still  into  the  incision  by  wdiich  the  ala  has  been 
shoved  ^down.  This  usually  leaves  but  little  scar  because  the  raw  surface 
from  which  the  flap  is  taken  can  be  sutured  to  correspond  -with  the  naso- 
labial fold.  The  principle  of  the  Wharton  Jones  operation  on  the  eye 
can  sometimes  be  employed,  making  a  V-shaped  incision,  shoving  doAvn 
the  edge  of  the  ala  and  suturing  the  resulting  wound  as  a  Y  (Figs.  234  and 
235),  Sometimes  a  flap  of  mucosa  can  be  taken  from  the  septum  of  the  nose 
with  its  base  at  the  tip  of  the  nose. 

If  considerable  cartilage  is  destroyed,  or  if  a  large  hole  is  left  it  will  be 


226 


OPERATIVE    SURGERT 


necessary  to  line  the  nasal  surface  of  the  flap  with  epithelium.  This  can 
sometimes  be  done  by  a  flap  of  mucosa  from  the  septum  of  the  nose.  I  have 
done  this  with  considerable  satisfaction  in  a  case  in  which  there  was  a  de- 
fect in  the  ala  following  the  application  of  a  paste.  The  procedure  is 
shown  in  the  accompanying  illustrations  (Figs.  236,  237,  238,  239,  240,  and  241). 
This  flap  is  turned  into  the  defect  and  the  pedicle  is  subsequently  cut.  This 
mucosa  often  matches  the  skin  verv  well.     If  the  defect  is  large  and  there  is 


Fig.   236. — Photograph   showing   defect   in   the   nose   caused   by   application    of   paste. 


Fig.   237. 


Fig.   238. 


Fig.   239. 


Fig.    240. 


Fig.  237. — Lines  of  incision  for  correcting  defect  shown  in  Fig.   235. 

Fig.  238. — The  small  bridge  of  tissue  is  cut  away. 

Fig.  239. — A  flap  is  formed,  constituting  the  lower  border  of  the  ala. 

Fig.  240. — A  flap  from  the  mucosa  of  the  .septum  as  indicated  in  Fig.  238   is  turned   into  the  wound. 


Fig.   241. — The   pedicle   to   this  flap   is  severed   and   the   flap   sutured   into   position. 

much  surrounding  scar  tissue  the  skin  flap  is  first  raised  and  then  covered 
with  a  Thiersch  graft,  or  a  flap  from  the  skin  along  the  margin  of  the  defect  is 
turned  into  the  wound  so  that  it  hinges  on  one  margin  of  the  defect  and  is 
sutured  with  its  raw  surface  outward  to  the  other  margin  of  the  defect  which 
has  been  previouslj^  freshened  by  cutting  off  a  small  ribbon  of  tissue  with  a 
sharp-pointed  knife.  Another  flap  is  turned  up  from  the  nasolabial  fold  to 
cover  the  raw  surface  of  the  first  flap.  Sometimes  with  extensive  scaring  and 
sinking  of  this  portion  of  the  nose  it  is  best  to  remove  the  scar  tissue  and  skin 


FACE    AND    MOUTH 


227 


from  tiie  siiiikiMi  jnirtioii  of  the  nose  that  lies  between  the  tip  of  the  nose  and 
the  nasal  bone,  and  transfer  a  flap  from  the  forehead. 

As  operations  for  defects  resulting  from  cancer  are  usually  done  in  elderh' 
people,  great  care  must  be  exercised  in  making  a  flap  with  a  long  narrow  pedicle. 
In  securing  a  flap  from  the  forehead  the  flap  should  first  be  outlined  with  its 
base  near  the  bridge  of  the  nose  to  include  an  angular  artery.  This  flap  ex- 
tends obliquely  across  the  forehead  and  that  portion  which  is  to  be  used  for 
reconstructive  purposes  should  be  as  near  the  hair  line  as  possible  so  that  any 
undue  scar  on  the  forehead  can  be  covered  bv  arrangement  of  the  hair.     This 


Fig.  242. — A  flap  from  the  forehead  has  been  turned  into  a  defect  in  the  tip  of  the  nose,  which 
also  resulted  from  the  application  of  paste.  The  tip  of  this  flap  is  being  gradually  severed.  ISiote  the  in- 
cision on  a  level  with   the  ej'e,   through  two-thirds   of  flap. 


Fig.  243. — Lines  of  incision  for  operation  of  Xela- 
ton   for   correction   of  defect   of   the   ala. 


Fig.   244. — The  operation  of   Nelaton  completed. 


flap  is  dissected  free  except  at  its  two  extremities  and  tlie  principle  of  gradual 
incision  that  has  been  already  discussed  (p.  178)  is  utilized.  The  part  of  the 
flap  that  is  to  be  severed  is  cut  by  short  incisions  beginning  about  the  fourth  daj^ 
after  the  operation  (Fig.  242),  or  else  it  is  clamped  for  an  hour  at  a  time  wdth  soft 
clamps  that  will  not  injure  the  tissues,  beginning  about  the  fourth  day  after 
operation.  In  this  way  the  blood  supply  is  developed  from  the  pedicle  of  the  flap 
and  its  distal  attachment  can  be  completely  severed  in  about  twelve  days.  It  is 
turned  down  with  some  periosteum  and,  if  desired,  small  chips  of  attached  bone, 


228 


OI'ERATIVE    SURGERY 


wlii;:;li  are  removed  from  the  skull  with  a  chisel.  It  is  sutured  into  the  defect  and 
after  ten  days  or  two  weeks  the  pedicle  is  severed,  cutting  a  third  every  two  days, 
and  returned  to  fill  up  as  much  of  the  defect  in  the  forehead  as  possible. 

A  flap  to  correct  a  defect  in  the  ala  can  sometimes  be  taken  with  its  base 
near  the  angle  of  the  eye  so  that  the  incised  wound  will  lie  in  the  fold  between 
the  nose  and  the  cheek  (Figs.  243  and  244).  The  columna  of  the  nose  can 
be  restored  by  taking  a  flap  of  skin  from  the  tip  of  the  nose  and  turning  it  down, 
or  by  the  method  of  Lexer,  who  obtains  a  flap  from  the  mucosa  of  the  upper 


Fig.  245. 


Fig.  247. 


Fig.   245. — Lines   of  incision  for  the   operation   of  Eexer  for   the   restoration    of   the   columna. 
Fig.  246. — A  flap  is  taken  from  the  mucous  surface  of  the  under  lip,  with  the  base  toward  the   nose. 
Fig.   247. — The    operation    of   Lexer   completed.      The   flap   is   brought   through    the   transverse    incision 
in  the  lip  and  is  attached  by  two  sutures  to  the  nose. 


248 


Fig.    249. 


Fig.   248. — Lines  of  incision   for   operation   of  J.   S.    Davis   for   restoration   of   the   columna. 
Fig.  249. — The  flaps   outlined  in  the  previous  figure  are  turned   into   position. 


lip  with  its  base  at  what  would  be  the  normal  base  of  the  columna.  The  lip 
is  perforated  at  this  point  and  the  flap  drawn  through  and  sutured  to  the 
tip  of  the  nose  (Figs.  245,  246  and  247). 

The  operation  of  J.  S.  Davis  for  restoring  the  columna  consists  in  taking 
two  quadrangular  flaps  from  the  upper  portion  of  the  upper  lijD  with  their 
pedicles  close  to  the  midline  near  the  anterior  margin  of  the  floor  of  the  nose  and 
with  the  free  ends  beyond  the  alae.  The  flaps  are  turned  inward  with  the  raw 
surfaces  approximated  to  each  other  and  the  tips  of  the  double  flap  attached 


FACE    AND    MOUTH 


229 


to  the  tip  oC  i\w  nose   (Fi^'s.  248  and  24!)).     This  opci'ation  is  only  suited  for 
individuals  avIio  have  a  very  lon<i'  upii(>r  lip. 

Recoustruetion  of  the  nose  in  which  all,  or  a  major  portion  of  the  nose  has 
been  destroyed  is  au  operation  that  requires  skill  and  patience.  Too  frequently 
the  illustrations,  in  order  to  show  the  steps  of  the  operation,  give  the  impression 
that  it  is  comparatively  easy  and  that  the  desired  results  can  be  obtained  with 
one  or  two  operations.  This  is  far  from  true  and  unless  any  plastic  operation 
upon  the  nose  is  well  planned,  skilfully  executed,  and  followed  by  a  number 
of  minor  operations  for  corrective  purposes,  the  results  will  be  unsatisfactory 
to  the  patient  and  somewhat  humiliating  to  the  surgeon.  This  is  particularly 
true  when  operations  are  undertaken  for  reconstruction  of  practically  the  whole 
nose.  Such  plastic  Avork  necessarily  is  done  by  flaps,  and  flaps  from  the  cheek 
while  furnishing  abundant  material  for  partial  defects  are  insufficient  for  all 


Fig.    250. — Lines   of   incisiuu    for   the    oiJuiaUou   of    Languubcck   for   reconstruction    of   the    nose. 


of  such  an  extensive  repair.  The  two  practical  methods  are  by  securing  a  flap 
from  the  forehead,  called  the  Indian  method,  or  obtaining  a  flap  from  some  dis- 
tant part,  as  the  arm  or  neck,  called  the  Italian  method.  Wherever  the  flap 
is  obtained  it  should  be  carefully  outlined,  preferably  with  a  pattern  that 
can  be  cut  from  rubber  dam,  which  is  easily  sterilized.  The  flap  should  be  at 
least  a  third  larger  than  appears  necessary  in  order  to  allow  for  shrinkage. 

The  Indian  method,  taking  flaps  from  the  forehead,  has  numerous  modi- 
fications. The  principle,  however,  is  illustrated  in  operations  such-  as  those  of 
Langenbeck  (Fig.  250)  or  Labat-Blasius  (Figs.  251  and  252).  In  these  opera- 
tions the  base  of  the  flap  is  so  placed  that  it  will  secure  the  nutrition  of  the 
angular  artery  from  the  inner  corner  of  the  eyebrow  and  the  flap  is  carried 
either  straight  up  or  to  one  side,  depending  somewhat  upon  the  length  of  the 
nose  and  the  character  of  the  forehead.  The  flap  should  be  so  placed  that  the 
twisting  to  bring  it  in  position  will  not  be  too  great.     It  is  best  to  outline  a 


230 


OPERATIVE    SURGERY 


columna  in  the  flap.  If  the  patient  is  old  and  there  is  reason  to  snspeet  in- 
snffieient  nntrition  the  flap  can  be  first  outlined  and  dissected  free  except 
at  its  pedicle  and  at  its  tip.  Rubber  tissue  is  carried  beneath  the  flap,  and  the 
distal  portion  is  gradually  severed  to  develop  a  blood  supply  at  the  base,  a  prin- 
ciple that  has  already  been   emphasized.      Some   operators,   as   Lang-enbeck   or 


Fig.    251. — Lines   of   incision    for   the   operation   of 
Labat-Blasius    for    reconstruction    of    the    nose. 


Fig.  252. — Flaps  outlined  in  the  preceding  illus- 
tration have  been  dissected  and  sutured  to  con- 
struct the   alas   of  the   nose. 


Labat-Blasius,  prefer  to  construct  the  columna  and  the  alse  of  the  nose  at 
the  extremity  of  the  flap  about  ten  days  or  two  weeks  before  turning  down  the 
flap  so  that  the  nostril  has  a  lining  of  the  tucked  edges  of  the  flap. 

If  the  bony  framework  of  the  nose  has  been  destroyed  it  will  be  necessary  to 
provide  some  cartilagenous  or  bony  support.  This  is  done  preferably  before 
the  flap  is  turned  down  though  it  can  be  done  after  the  soft  tissues  have  been 


Fig.  253. — Lines  of  incision  for  operation  of  Keegan   for  reconstruction   of  the   nose. 

placed.  If  it  is  done  beforehand,  a  thin  section  of  the  skull  may  be  chiseled  up 
along  with  the  flap.  This  is  difficult  of  execution  and  it  is  even  more  difficult 
to  prevent  displacement  of  the  bone  from  the  flap.  Such  a  flap,  too,  must  be  in- 
variably turned  onto  the  raw  surface  of  another  flap  having  its  epithelial 
surface  internal  and  lining  the  cavity  of  the  nose. 

It  is  an  essential  principle  in  any  complete  reconstruction  operation  on  the 


FACE    AND    MOUTH 


231 


nose  tliat  tlie  flap  ^vitll  which  tlio  nose  is  made  nnist  have  an  epithelial  lining 
on  its  internal  snrface.  The  older  operations  which  did  not  provide  for  this 
were  seldom  satisfactory.  Great  improvement  has  been  made  in  reconstruction 
of  the  nose  by  first  lining  the  flaps  with  epithelium  by  Thiersch  grafts,  before 
they  are  put  in  position,  or  by  turning  in  a  pedicle  flap  from  the  cheek,  and 
by  forming  a  supporting  frame  work  preferably  by  the  insertion  of  strips  of 
cartilage.  If  there  is  a  small  amount  of  tissue  left  at  the  bridge  of  the  nose 
two  flaps  can  be  turned  down  according  to  the  method  of  Keegan  (Fig.  253) 
with  their  bases  at  the  upper  margin  of  the  defect  of  the  nose,  or  we  may  use 
the  method  of  Thiersch,  in  which  preliminary  flaps  are  turned  in  from  the 
cheek  with  the  base  of  each  flap  hinging  on  the  lateral  margins  of  the  defect 
(Fig.  254).  This  can  be  done  at  the  same  time  that  the  frontal  flap  is  turned 
in  position  so  that  both  raw  surfaces  can  be  approximated,  which  will  prevent 
infection  and  at  the  same  time  will  be  mutually  helpful  to  both  flaps  in  the 


Fig.  254. — Lines  of  incision  for   operation  of  Thiersch  for  reconstruction   of  the  nose. 


blood  supply.  After  turning  the  flaps  in  position  they  are  sutured  with  inter- 
rupted fine  silkworm-gut,  horsehair,  or  silk.  The  pedicle  of  the  frontal  flap  is  cut 
in  from  ten  to  fourteen  days.  Eeconstructive  operations  under  local  anes- 
thesia should  be  done  at  intervals  of  a  few  weeks  until  a  satisfactory  result 
is  obtained. 

The  Ifolian  method  of  obtaining  flaps  from  the  arm  or  neck  has  the  advan- 
tage of  not  leaving  a  conspicuous  scar  on  the  forehead,  but  the  disadvantage 
of  causing  considerable  discomfort  to  the  patient  who  is  forced  to  keep  the 
arm  to  the  head  for  several  da.vs.  These  flaps  are  outlined  on  the  arm  with 
the  base  near  the  elboAV.  The  arm  is  first  placed  on  the  head  and  the  flap  is 
marked  out  in  such  a  manner  that  the  arm  can  be  held  in  as  comfortable  a 
position  as  possible  after  the  flap  has  been  applied  to  the  nose.  If  the  bony 
frame-work  of  the  no.se  is  lacking  it  is  best  to  transplant  cartilage  under  the 
flap  and  dissect  the  flap  partly  free  three  or  four  weeks  before  the  flap  is 
applied  to  the  nose.  The  flap  can  be  taken  from  the  forearm.  Israel  recom- 
mends a  flap  from  the  forearm  with  the  pedicle  up  and  the  tip  near  the  lower 
end  of  the  ulna  (Fig.  255).  He  removes  the  subjacent  portion  of  the  ulna  bone, 
taking  a  strip  of  the  ulna  one-third  of  an  inch  wide  by  about  two  and  one-half 


232 


OPERATIVE    SURGERY 


inches  long-.  This  is  remoA^ed  with  a  fine  saw  in  order  not  to  fracture  the 
iihia.  The  skin  tlap  with  the  ulna  attached  is  first  outlined  and  the  bone  is 
separated  except  at  its  upper  end  which  is  left  attached  for  about  nine  days. 
The  nose  is  modeled  as  well  as  possible  on  the  forearm  and  about  twelve  days 
after  the  graft  from  the  ulna  has  been  separated  the  flap  is  sutured  to  the 
nose,  the  arm  being  held  in  position  for  two  weeks  (Fig.  256). 

The  flaps  from  the  arm  for  complete  reconstruction  of  the  nose,  like  those 
from  the  forehead,  should  contain  cartilage,  if  bone  is  not  provided  for  as  in 
the  method  of  Israel.  The  cartilage  is  inserted  between  the  skin  and  the  deeper 
layers  of  fat  and  is  permitted  to  stay  in  this  position  for  at  least  two  or  three 
weeks  before  attempting  to  outline  the  flap  or  suture  it  to  the  nose.  Carti- 
lage appears  to  be  much  better  than  bone,  as  it  can  be  molded  satisfactorily  and 
unlike  bone  does  not  tend  to  atrophy  and  absorb.  Cartilage  is  obtained  from 
the  costal  cartilages. 


Fig.  255. — Lines  of  incision  for  operation  of 
Israel  for  reconstruction  of  the  nose  by  a  flap 
from  the  forearm. 


Fig.  256. — The  flap  from  the  forearm  has  been 
dissected  free  and  is  sutured  into  position  on  the 
face. 


Mandry  has  suggested  a  flap  from  the  neck  which  includes  a  portion  of  the 
clavicle. 

A  few  operations  have  been  done  in  w^hich  the  finger  has  been  used  as  a 
substitute  for  the  nose.  Davis-  says:  ''I  have  noted  that  a  surgeon  seldom  re- 
ports more  than  one  case  operated  upon  by  this  method.  This  may  be  due  to 
the  fact  that  only  one  patient  requiring  this  kind  of  operation  has  come  under 
his  care,  but  my  feeling  is  that  it  is  unnecessary  to  lose  a  finger  when  better 
results  can  be  olrtained  by  other  methods."  If  this  operation  is  done  the  tech- 
nic  of  Baldwin  appears  to  give  the  best  results.  Baldwin  uses  the  ring  finger 
of  the  left  hand,  which  is  split  in  the  midline  on  the  palmar  surface,  and  trans- 
verse incisions  are  made  at  the  level  of  the  nail  and  at  the  base  of  the  finger 
(Fig.  257).     The  tip  of  the  finger  including  the  nail  and  its  matrix  is  removed 


aplastic   Surgery,  by  Davis,  J.   S.     Philadelphia,   P.  Elakiston's   Son  &   Co.,  p.  467. 


FACE    AND    MOUTH 


233 


aiul  the  fin<i'rr  transplanted  to  the  defect  in  the  nose,  which  has  previously  been 
prepared  so  that  tlie  raw  surface  of  the  distal  phalanx  of  the  bone  is  imbedded 
into  a  jnt  <i'ouiied  (uit  of  the  frontal  bone  at  the  upper  part  of  the  bridge  of  the 
nose. 

A  reconstructed  nose  must  have   a  number   of  minor  plastic  operations 
in    order    to    secure    satisfactory    results.      These    operations    are    also    some- 


Fig.  257. — Dissection  of  a  flap  from  the  finger  as  the  first  stage  in  the  operation  of  Baldwin  for  recon- 
struction of  the  nose   from  a   finger. 

times  done  on  noses  that  are  congenitally  misshaped.  The  size  of  the  nose 
may  be  reduced  by  the  method  of  Joseph  in  which  a  long  narrow  triangular  flap 
of  tissue  is  taken  from  the  anterior  border  of  the  nose  with  the  apex  at  the 
bridge  of  the  nose.    At  the  base  of  this  triangle  on  the  tip  of  the  nose  a  small 


Fig.    258. — Lines   of    incision    for   the   operation    of   Joseph    for    reconstruction    of   the    nose. 

triangle  of  tissue  at  the  bottom  of  the  larger  triangle  is  left  (Fig.  258). 
If  the  bone  is  too  large  it  can  be  resected  with  a  fine  saw  or  chisel  but  care 
should  be  taken  to  preserve  the  excised  cartilage  and  to  avoid  opening  the  nasal 


234  OPERATIVE    SURGERY 

mucosa  if  possible.  When  a  sufficient  amount  of  bony  and  cartilagenous  tissue 
has  been  removed,  strips  of  the  preserved  cartilage  are  replaced  on  the  nasal 
mucosa  in  a  manner  to  give  a  symmetrical  outline  when  the  skin  is  sutured. 

If  one  ala  is  too  low  it  may  be  corrected  by  the  method  of  Joseph  (Figs. 
259  and  260)  or  by  making  a  straight  incision  on  the  anterior  border  of  the 
nose  from  the  bridge  to  the  tip  and  then  taking  out  a  small  triangle  of  tissue 
on  the  side  that  is  too  low.  The  base  of  this  triangle  should  rest  on  the  long 
incision  (Figs.  261  and  262).  If  the  nose  is  too  short  it  can  be  lengthened  by 
a  \ -shaped  incision  with  the  apex  on  the  bridge  of  the  nose,  as  recommended 
by  Pirogoff  (Figs.  263  and  264).  The  tissues  are  thoroughly  loosened  and  the 
wound  is  sutured  in  the  form  of  a  Y,  utilizing  the  principle  of  the  Wharton 
Jones  operation  for  ectropion.    In  this  manner  the  tip  of  the  nose  is  shoved  down. 

If  the  nose  is  too  broad  a  triangular  area  can  be  excised  from  the  upper 
lip  with  its  base  on  the  floor  of  each  nostril  and  the  apex  near  the  ver- 
milion border.  This,  of  course,  may  be  modified  for  one  side  if  one  nostril 
spreads  more  than  another.  Noses  that  are  too  broad  and  flat  may  be  corrected 
by  excising  a  V-shaped  section  from  each  ala  and  suturing  the  cartilage  accu- 
rately from  within  the  nostril.  If  the  tip  of  the  nose  is  too  broad  this  can  be 
corrected  by  taking  a  V-shaped  section  from  the  anterior  part  of  each  nostril 
(Figs.  265  and  266). 

A  rather  common  and  disfiguring  deformity  is  the  so-called  ''saddle  nose," 
or  flattening  of  the  bridge  of  the  nose.  This  may  follow  trauma  or  disease  and  if 
marked  is  always  accompanied  by  turning  up  of  the  tip  of  the  nose.  The  most 
satisfactory  operation  for  this  deformity  is  the  transplantation  of  cartilage. 
Carter,  of  New  York,  has  had  extensive  experience  with  this  operation  and  uses 
a  rib  or  a  piece  of  cartilage,  and  makes  the  incision  either  across  the  bridge  of 
the  nose  or  from  within  the  nostril.  If  the  tip  of  the  nose  is  markedly  turned 
up,  it  should  be  corrected  by  massage  and  after  the  nutrition  of  the  skin  has  been 
developed  the  operation  of  Pirogoff  in  which  a  V-shaped  incision  is  made  and 
sutured  as  a  Y  may  be  performed  for  lowering  the  tip.  The  transplantation  of 
cartilage  is  then  postponed  for  at  least  a  month.  If  the  turning  up  of  the  tip 
of  the  nose  is  not  very  marked  this  can  be  corrected  by  the  implantation  of  the 
cartilage.  In  implanting  the  cartilage  through  an  external  incision,  which  in 
many  respects  is  preferable,  a  short  incision  is  made  across  the  bridge  of  the 
nose  about  on  the  level  of  the  inner  ,canthi  of  the  eyes.  The  incision  may  be 
slightly  higher  or  lower  than  this,  depending  upon  the  deformity.  The  perios- 
teum is  also  incised  and  undermined  until  the  junction  of  the  nasal  and  frontal 
bones  is  reached.  Over  the  bridge  of  the  nose  a  tannel  is  then  made  from  the 
incision  to  the  tip  of  the  nose  by  inserting  a  pair  of  closed  scissors  and  grad- 
ually opening  them.  This  tunnel  shouVl  be  sufficiently  large  easily  to  admit  the 
graft  and  to  free  any  marked  adhesions,  but  should  extend  no  further  on  the 
side  of  the  nose  than  is  necessary.  It  is  made  between  the  skin  and  the  peri- 
osteum. With  a  bent, probe  the  measurement  of  the  length  of  the  transplant  is 
made  and  cartilage  is  cut  from  the  costal  cartilage  of  a  rib,  near  the  costal 
arch.     If  possible  the  perichondrium  on  one  side  of  the  cartilage  is  preserved. 


FACE   AND    MOUTH 


23J 


Fig.    259. — The    denudation    according    to    Joseph 
for  the   elevation   of  a   drooping  ala. 


Fig.    260. — Operation   as   outlined   in   the   preceding 
illustration  is   completed. 


Fig    261. — Ivines  of  incision  for  operation   of  Dief- 
fenbach  for  elevation   of  one  side  of  the  nose. 


Fig.    262. — Operation    of    Dieffenbach    completed. 


Fig.    263. — Ivines   of   incision    for    operation    of    Pi- 
rogoff  for  lowering  the  tip  of  the  nose. 


Fig.    264. — Operation    of   Pirogoff   completed. 


Fig.  265. — Lines  of  incision  for  operation  of  Kolle 
for    reconstruction    of    nostrils. 


Fig.    266. — Operation    of   Kolle   completed. 


236 


OPERATIVE    SITRGERY 


The  cartilagenous  graft  is  trimmed  to  what  appears  to  be  satisfactory  shape 
and  inserted.  It  is  important  not  to  trim  too  much  at  first  for  it  is  better  to 
have  it  too  large  when  first  inserted  than  too  small,  as  the  former  defect  can  be 
readily  corrected.  After  it  has  been  made  to  fit  satisfactorily,  the  wound  over 
the  nose  is  closed  witli  fine  sutures  of  silkworm-gut  or  silk.  A  gauze  dressing 
carefully  applied  or  better,  a  cast  of  paraffine,  which  is  renewed  every  day  for 
a  week,  is  used  to  keep  the  graft  in  position  and  the  nose  in  satisfactory  shape. 

THE  FOREHEAD 

Occasionally  by  injury  or  disease  the  anterior  bony  wall  of  the  frontal 
sinus  is  destroyed.  This,  if  accompanied  by  injury  to  the  overlying  soft  tissues, 
makes  a  very  marked  deformity.    Three  cases  of  this  type  that  I  have  had  were 


Fig.  267. — Lines  of  incision  for  closure  of  de- 
fect in  frontal  sinus  o*  the  patient  shown  in  Fig. 
270.  The  black  area  is  the  defect.  Flaps  C  and 
D  were   turned   in  with  the   epithelial  side  inward. 


Fig.  268. — After  suturing  the  edges  of  flajis  C  and 
D,  flaps  A   and  B   are  freed. 


Fig.   269. — Flaps   A    and   B   are   sutured   as   shown. 


Fig.  270.— Photograph  of  patient  E.  W.  S. 
taken  before  operation.  The  defect  followed  a 
fracture  and  necrosis  of  the  frontal  bone. 


'1. — Photograph   of   E.   ^^'.    S-    two   weeks 
after   operation. 


FACE   AND    MOUTH 


237 


Fig.    272. — The   incisions    for    repair   of    defect    in    the    frontal    sinus    wlicn    there    is    no    depression.      A    small 
flap    of   pericranium    can   be   turned    into    the    defect. 


Fig.   273. — The   forehead   has   been   mobilized   and   the   wound    is   sutured    with   a    subcuticular   stitch. 


Fig.  274. — Photograph  of  patient  S.  H.  two  weeks  after  operation  as  described  in  the  two  preceding  figures. 

all  due  to  trauma.  To  close  the  opeuiug  and  to  remedy  the  depression,  flaps  are 
taken  from  the  margin  of  the  opening  into  the  frontal  sinus,  with  their  bases 
hinging  on  the  margin.  It  is  best  to  take  flaps  from  both  sides  of  the  opening 
and  to  strip  up  the  periosteum.    Before  flaps  are  formed  or  turned  in,  however, 


238  OPERATIVE   SURGERY 

a  large  probe  is  inserted  into  the  frontal  sinus  and  brought  out  into  the  nose 
and  a  strip  of  gauze  is  attached  by  a  thread  to  the  end  of  tlie  probe  and  car- 
ried through  tlic  infundibulum  opening.  The  gauze  is  drawn  back  and  fortli 
in  order  to  enlarge  this  opening  and  to  provide  ample  drainage  of  any  ex- 
foliated material  from  the  inverted  flap.  These  flaps  are  united  with  fine  tanned 
catgut  sutures  (Figs.  267,  268,  269,  270  and  271).  If  the  depression  is  abrupt 
and  not  very  large  the  raw  surface  of  the  inverted  flaps  can  be  covered  by  a 
transverse  incision  which  extends  outward  from  each  end  of  the  defect.  The 
whole  of  the  forehead  is  mobilized  by  undermining,  is  slid  down  to  cover  the 
raw  surface  of  the  inverted  flaps,  and  is  sutured  as  a  straight  wound  to  the 
margin  of  skin  just  over  the  eyebrows.  This  falls  in  the  natural  crease  and 
makes  a  verj^  inconspicuous  scar  (Figs.  272,  273,  and  274).  If,  however,  the 
defect  is  a  larger  one  with  gradually  sloping  sides  it  will  be  necessary'  to  use 
flaps.  This  can  be  done,  as  shown  by  the  accompanying  illustrations,  by  having 
the  flap  with  its  base  over  one  eyebrow  and  its  apex  toward  the  hairline.  This 
is  turned  down  and  sutured  across  the  defect  and  the  raw  surface  is  covered  by 
sliding  a  flap  from  the  upper  margin  of  the  defect  in  the  frontal  sinus  across, 
to  fill  up  the  raw  surface  left  by  removing  the  large  flap. 

TUMORS  OF  THE  FACE 

Tumors  of  the  face  are  common,  particularly  benign  tumors  such  as  warts 
or  moles.  The}"  are  best  removed  by  an  excision  which  includes  a  small  amount 
of  surrounding  healthy  tissue.  The  defect  is  then  repaired  by  utilzing  some  of 
the  plastic  procedures  that  have  already  been  described.  If  the  growth  is  a 
malignant  one  a  wider  margin  of  healthy  tissue  should  be  taken  and  the  removal 
either  done  with  an  electric  cautery,  or  else  the  raw  surface  left  by  the  removal 
is  thoroughly  cauterized.  In  benign  lesions,  however,  where  a  cautery  is  unnec- 
essary, excision  and  careful  suturing  of  the  wound  will  leave  a  very  inconspic- 
uous scar.  Usually  such  operations  are  performed  under  local  anesthesia,  though 
on  account  of  the  inflltration  of  the  tissues  a  local  anesthetic  is  not  apt  to  be 
followed  by  as  satisfactory  healing  as  is  a  general  anesthetic  where  no  infiltra- 
tion is  necessary.  The  wart  or  mole  is  circumscribed  by  an  incision,  usually 
diamond-shaped,  wdth  the  growth  in  the  center  of  the  area.  The  incision 
is  made  with  a  sharp-pointed  knife  and  the  cut  carried  through  the  full 
thickness  of  the  skin.  After  the  growth  is  removed  the  edges  of  the  skin  are 
undercut,  and  bleeding  is  controlled  by  clamping  the  vessels  with  mosquito 
forceps  and  tying  or  suturing  them  with  fine  catgut.  The  deeper  layers  of  the 
skin  are  brought  together  with  a  continuous  suture  of  fine  plain  catgut,  tanned 
or  chromic  catgut  causing  too  much  irritation.  The  skin  is  united  accurately 
by  a  continuous  epithelial  stitch  of  arterial  00000  silk.  A  fine  subcuticular 
suture  of  silkworm-gut  is  also  an  excellent  method  of  closure  and  the  epithelial 
stitch  may  be  used  over  it.  (Figs.  275,  276,  277,  278  and  279.)  A  light 
compress  of  dry  gauze  is  kept  over  the  w^ound  for  twenty-four  hours  to  prevent 
swelling.     The  stitches  are  removed  at  the  end  of  the  sixth  or  seventh  dav. 


PACE    AND    MOUTH  239 

Wlierever  possiljlc  llic  loii^-  diameter  of  the  diamoiid-sliaped  incision  should 
cori'es]ioiid  to,  or  be  parallel  with,  the  natural  folds  or  creases  of  the  skin. 
This  will  add  greatly  to  the  inconspicuousness  of  the  scar. 

If  the  growth  is  cancerous  it  should  first  be  thorougldy  cauterized  with 
an  electric  cautery  to  prevent  implantation.  If  a  local  anesthetic  is  used  it  is 
important  to  insert  the  needle  in  healthy  tissue  at  some  distance  from  the  can- 
cer so  that  the  infiltrating  fluid  is  always  carried  toward  the  growth.  In  this 
way  the  cancer  cells  will  not  be  forced  away  from  the  cancer.  If  the  growth  is 
excised  with  a  knife  instead  of  an  electric  cautery  the  raw  surface  left  is  imme- 
diately gone  over  with  the  cautery.  Such  a  wound  may  be  left  open  for  a  week 
or  longer  and  can  then  be  closed  or  grafted.  No  effort  should  ever  be  made 
to  excise  a  cancerous  growth  on  the  face  with  a  knife  and  suture  it  at  once  merely 
in  order  to  secure  a  good  cosmetic  result.  Attention  must  first  be  focused  on 
curing  the  cancer  and  after  this  has  been  apparently  accomplished  a  plastic 
operation  may  be  undertaken  to  provide  a  satisfactory  cosmetic  result. 

Angiomas  are  common  along  the  lips  or  on  the  tip  of  the  nose.  If  small 
and  circumscribed,  they  may  be  excised  in  the  same  manner  as  has  been  de- 
scribed for  nonmalignant  tumors.     If  they  are  large,  a  satisfactory  method  of 


Fig.  275.  .        Fig.   276 


Fig.  275. — Lines  of  incision  for  excision  of  a  benign  tumor  of  the  face.  The  vertical  angles  of  the 
incision   may   be   made   closer  to   the   growth. 

Fig.  276. — The  growth  has  been  excised  and  the  skin  and  subcutaneous  tissue  are  thoroughly 
mobilized. 

Fig.   277. — The   superficial   fascia  and   fat    is   approximated   with   a   continuous   suture   of   plain   catgut. 

Fig.  278. — The  deep   layer  of  the  skin  is  united  with  a  subcuticular   suture  of  fine  silkworm   gut. 

Fig.  279. — The  epithelial  layers  are  united  with  a  superficial  stitch  of  very  fine  silkworm  gut  or  of 
arterial  silk.      (Epithelial  stitch   of  Halsted.) 

treatment  is  by  the  injection  of  hot  water,  which  was  first  devised  by  John  A. 
Wyeth,  of  New  York.  The  water  should  be  injected  at  a  temperature  of  from 
180  degrees  to  boiling  point.  Francis  Reder,  of  St.  Louis,  has  developed  this  tech- 
nic  in  a  very  satisfactory  manner.  The  principle  is  that  the  hot  water  destroys  the 
endothelial  lining  of  the  blood  vessels  composing  the  angioma  and  causes  clot- 
ting within  the  vessels  of  the  tumor.  In  large  angiomas  it  is  best  to  inject  at 
different  sittings,  injecting  only  a  portion  of  the  tumor  at  each  sitting.  If  the 
growth  is  in  the  neighborhood  of  the  eye  or  if  the  general  health  of  the  patient 
is  poor,  damage  may  be  done  by  injecting  too  much  hot  water.  Wyeth  uses  an 
all-metal  sj^nnge,  which  can  be  further  heated  after  the  water  has  been  drawn 
into  it.  Reder  finds  an  all-glass  syringe  with  an  asbestos  plunger  to  be  satisfactory. 
He  uses  thick  gloves  and  injects  the  water  as  hot  as  possible.  The  tissues  around 
the  tumor  are  protected  with  moist  cloths  and  the  surface  of  the  growth  may 
be  anointed  with  sterile  vaseline.    The  point  of  the  needle  is  carried  well  beneath 


240  0PERA.T1VE    SURGERY 

the  skin  before  beginning  tlie  injection.  When  the  angioma  is  moderately  dis- 
tended and  the  heat  of  the  water  can  be  distinctly  felt  with  the  bare  finger  on 
the  skin,  the  injection  shonld  be  discontinned.  The  needle  may  be  removed  and 
inserted  at  a  different  point.  Several  ounces  of  hot  water  can  be  injected  at  one 
sitting  if  the  growth  is  large.  Soon  after  injection  extensive  swelling  may 
appear,  which  can  be  controlled  to  some  extent  by  cold  compresses.  If  neces- 
sary, the  injection  may  be  repeated  at  intervals  of  from  two  to  three  weeks. 

THE  PAROTID  GLAND 

The  nsual  indications  for  operations  on  the  parotid  gland  are  tumors  or  a 
fistula.  Fistulous  openings  ccme  from  wounds  and  may  be  so  annoying  that  a 
large  amount  of  saliva  flows  from  the  fistula  during  mastication,  or  there  may  be 
only  a  few  occasional  drops.  If  the  fistula  is  in  Steno  's  duct  it  is  readily  corrected 
by  the  operation  of  Deguise.  A  silver  wire  is  threaded  in  a  curved  needle  and 
passed  from  the  external  fistula  through  into  the  cavity  of  the  mouth.  The  ex- 
ternal end  of  the  wire  is  threaded  on  another  needle  and  also  passed  in  the 


cuAarxeou-s    suvfac-e- 

Fig.  280. — Method  of  Deguise  for  closing  salivary  fistula  of   Steno's  duct. 

mouth  at  a  distance  of  about  one-eighth  inch  from  the  point  of  insertion  of  the 
other  end  of  the  wire.  The  mouth  is  opened  and  the  two  ends  of  the  wire  are 
drawn  snugly  and  twisted.  The  ends  of  the  wire  are  cut  short.  The  skin  is  in- 
cised around  the  fistula  and  undercut.  It  is  sutured  over  the  fistula  with  fine 
silkworm-gut  or  horsehair  (Fig.  280).  The  wire  can  be  left  in  for  several  weeks 
until  the  skin  wound  has  firmly  healed.     The  mouth  should  be  kept  clean. 

If  the  fistula  is  from  the  substance  of  the  gland  itself  a  different  type  of 
operation  is  necessary.  Probably  the  most  satisfactory  remedy  for  this  condition 
is  the  operation  of  Grouse.  An  incision  about  one  and  one-fourth  inches  long 
is  made  through  the  skin  and  fat,  straight  downward  from  a  point  about  three- 
fourths  of  an  inch  below  the  zygoma  and  about  three-fourths  of  an  inch  in  front 
of  the  ear.  This  incision  will  avoid  injury  to  the  nerves  and  blood  vessels. 
The  fascia  covering  the  parotid  gland  is  exposed  and  an  incision  about  one- 
third  of  an  inch  long  is  made  into  the  fascia,  going  into  the  substance  of  the 
parotid  gland  (Fig.  281).  The  lip  on  the  same  side  as  the  affected  parotid  is 
grasped  with  gauze  and  the  cheek  turned  out  to  expose  the  mucosa.  A  flap  of 
mucosa  about  one-fourth  of  an  inch  wide  and  thick  enough  to  be  viable  is 
formed,  beginning  near  the  inner  border  of  the  lip  and  running  back  to  a  point 


FACE   AND    MOUTH 


241 


jiLsl  bcliiiul  1iu>  level  of  the  secoiul  iii)])er  molar  tooth,  the  pedicle  of  the  flap 
being  beliiud  (Fig.  282).  A  closed  curved  hemostatic  forceps  is  introduced 
througli  the  external  incision,  burrows  forward  close  to  tlie  surface  of  the  mas- 
seter  muscles,  and  is  forced  into  the  mouth  just  in  front  of  the  pedicle  of  mu- 
cosa. The  forceps  is  opened  to  dilate  the  tunnel  and  the  end  of  the  flap  is 
grasped,  pulled  through  the  tunnel  and  fastened  into  the  posterior  edge  of  the 
incision  into  the  fascia  of  the  parotid  gland  with  a  fine  chromic  catgut  suture. 
This  suture  is  passed  like  the  Lembert  intestinal  suture  to  tuck  the  end  of  the 
mucosa  under  the  incised  parotid  fascia.  The  ends  of  this  suture  are  left  long. 
A  mosquito  forceps  is  then  passed  into  the  external  wound  and  through  the 
tunnel  into  the  mouth,  and  seizes  the  middle  of  a  strand  of  No.  5  chromic  cat- 
gut, which  is  pulled  through  the  wound  and  tied  with  the  long  ends  of  the  fine 
catgut  suture  so  as  to  have  the  ends  of  the  stout  chromic  catgut  in  the  mouth 


i«H| 

BIHM 

B' 

^1 

■r 

/ 

^ 

^ 

^! 

f^,  . 

Hele^    Lc)-t'-/3 

)  -T^  G    . 

Fig.   281. — Operation    of   Grouse   for   closure   of   salivaiy   fistula   of    the   parotid.      The    first   incision   has   been 
made   and   the   forceps   are   tunneling   the   tissue. 


(Fig.  283).  This  makes  the  flap  of  mucosa  assume  a  tubular  shape  around  the 
stout  chromic  catgut.  The  external  wound  is  closed  in  the  usual  way  for  skin 
incisions. 

Tumors  of  the  parotid  may  be  small,  round,  and  rather  movable,  or  may  be 
of  a  malignant  infiltrating  nature.  The  small  movable  tumors  can  usually  be 
readily  excised  through  a  transverse  incision  through  the  skin  and  fascia  par- 
allel with  the  direction  of  the  branches  of  the  facial  nerve.  This  incision  is 
carefully  carried  flown  to  the  tumor  and  constant  watch  is  kept  for  any  branches 
of  the  facial  nerve,  not  only  watching  for  the  fibers  but  noticing  any  contraction 
of  the  muscles  of  the  face.  Any  suspicious  strand  is  gently  seized  with  a  del- 
icate forceps  to  test  whether  it  will  be  followed  b}^  contraction  of  the  facial 
muscles  before  it  is  cut.  This,  of  course,  should  be  carefully  done  because  a 
rough  handling  of  the  branches  of  the  facial  nerve  may  result  in  their  perma- 


242 


OPERATIVE    SURGERY 


nent  injury.  "When  the  capsule  of  the  tumor  is  readied  the  tumor  can  usually 
be  enucleated  by  blunt  dissection  Avith  curved  scissors,  introducing  the  closed 
scissors  close  to  the  tumor  and  spreading  them  open  after  they  have  been  intro- 
duced. This  Avill  gradually  stretch  the  tissues  and  permit  the  enucleation  of 
the  growth.  Bleeding  points  are  seized  with  mosquito  forceps  and  tied  with 
fine  catgut.     Tlie  fascia  should  receive  a  separate  row  of  catgut  sutures  before 


Fig.   282. — The   pedicle   of  a  flap   of   mucosa   is   formed   from   within   the   mouth. 


Fig.  283. — The  pedicle   of  mucosa  with   its  base   backward   has   Deen   orougnt  luiougn   with   the   forceps   from 
the   external   incision   and   is  fastened   into   the   parotid  gland. 


closing  the  skin.  If  for  any  reason  the  oozing  cannot  be  controlled  the  wound 
is  packed  with  gauze  for  five  or  ten  minutes,  the  gauze  removed  and  the  wound 
closed.  It  may  be  necessary  to  insert  a  fine  drain  into  the  cavity  left  by  the 
removing  of  the  growth,  but  it  is  best  to  avoid  this  if  possible  because  it  may  leave 
a  point  of  dimpling  in  the  scar  or  be  followed  by  a  parotid  fistula. 

If  the  tumor  is  large  and  cannot  be  removed  by  an  incision  immediately 


FACE   AND    MOUTH 


243 


over  it  without  makiii.u-  tlio  incision  so  lou^i'  as  lo  ciulaii^'or  the  branches  of  the 
facial  nerve,  it  can  be  approached  by  an  incision  nnder  the  angle  of  the  jaw, 
which  begins  abont  the  tip  of  tlie  mastoid  process,  runs  down  to  the  level  of  the 
angle  of  the  jaw,  and  then  forward  and  slightly  upward.  Tlie  skin  and  superficial 
fascia  are  turned  up  in  the  form  of  a  flap.  The  tumor  in  this  way  is  approached 
from  below  and  if  it  does  not  present  readily  at  this  point  an  incision  is  made 
into  the  gland  substance  over  the  tumor.  This  incision  into  the  parotid  should 
be  transverse,  in  the  general  direction  of  the  branches  of  the  facial  nerve.  If 
tlie  tumor  is  solid  and  the  capsule  strong  it  may  be  enucleated  by  blunt  dissec- 
tion, but  if  it  is  friable  with  a  weak  capsule  and  contains  semisolid  material  the 
contents  of  the  capsule  is  removed,  piecemeal.  The  tumor  should  be  attacked 
first  along  the  anterior  border,  then  the  posterior,  the  dissection  being  car- 
ried from  below  upward.  If  fragments  of  the  tumor  are  left  behind  they  can 
be  touelied  with  the  fine  point  of  an  electric  cautery,  though  the  burning 
should  be  made  with  caution  to  avoid  injury  to  the  facial  nerve.  The  cav- 
ity left  by  the  removel  of  a  large  tumor  will  require  drainage.  If  sutures  are 
necessary  to  check  bleeding  they  should  be  of  fine  plain  catgut  so  they  will  be 
readily  absorbed. 

In  malignant  growths  of  the  parotid  it  is  necessary  to  remove  the  entire 
gland  along  with  the  facial  nerve.  The  patient  should  always  be  informed  be- 
fore the  operation  of  the  necessity  of  causing  a  facial  paralysis  on  the  side 
of  the  face  in  which  the  tumor  is  located.  It  is  often  necessary  to  dissect 
out  the  glands  of  the  neck  when  a  malignant  growth  of  the  parotid  is  re- 
moved, and  if  this  is  to  be  done  the  incision  for  removal  of  the  parotid  is  so 
modified  as  to  afford  an  ample  exposure  for  a  block  dissection  of  either  the  upper 
portion  of  the  neck  or  the  whole  side  of  the  neck,  according  to  the  indications. 
In  malignancy-  in  the  parotid,  as  in  malignancy  elsewhere,  the  incision 
should  be  so  shaped  as  to  enable  the  operator  to  remove  the  gland  and  its  sur- 
rounding tissues  in  one  mass.  The  chief  aim  to  be  kept  in  mind  is  to  cure  the 
cancer.  A  straight  incision  is  made  from  the  zygoma  just  in  front  of  the  ear, 
downward  over  the  anterior  border  of  the  sternomastoid  muscle.  If  it  is  in- 
tended to  dissect  the  upper  triangle  of  the  neck  at  the  same  time  an  incision  is 
carried  beneath  the  border  of  the  jaw  to  the  midline  of  the  neck  about  one  inch 
below-  the  chin.  The  technic  of  block  dissection  of  the  neck  is  discussed  in  the 
succeeding  chapters. 

If  the  malignant  growth  in  the  parotid  appears  to  be  attached  to  the  skin 
the  first  incision  should  be  made  at  a  safe  distance  from  this  point  and  another 
incision  should  circumscribe  this  area  in  such  a  manner  as  not  to  touch  the  tis- 
sues at  this  point.  The  lower  end  of  the  cut  over  the  sternomastoid  muscle  is  deep- 
ened until  the  external  carotid  artery  is  exposed.  This  artery  is  ligated  a  short 
distance  above  the  superior  thyroid  branch.  It  is  best  to  put  another  ligature 
on  the  external  carotid  just  above  the  facial  branch  and  to  tie  the  facial,  the 
lingual  and  the  posterior  occipital  branches  if  they  can  be .  readily  exposed. 
This  not  only  decreases  the  bleeding,  but  on  the  principle  of  starvation  of  ma- 
licrnant  o-powths  as  advocated  by  Dawbarn,  it  may  somewhat  retard  the  ten- 


244 


OPERATIVE    SURGERY 


dency  of  reciirreuce  of  the  cancer.  The  edges  of  the  wound  are  then  thoroughly 
undercut  to  expose  the  parotid  and  its  contained  growtli  as  full}'  as  possihle.  If 
the  dissection  of  the  parotid  is  undertaken  with  a  cutting  electric  cautery  that 
has  a  stout  enough  hlade  to  allow  some  pressure  the  operation  will  be  greatly 
facilitated.  The  parotid  can  then  he  readily  enucleated  with  the  red  hot  cau- 
tery by  dissecting  from  before  backward.  The  cautery  follows  readily  the  line 
of  cleavage,  lessens  the  bleeding,  destroys  cancer  cells  in  its  way,  and  closes  the 
lymphatics  which  might  otherwise  take  up  cancer  cells.  AVhen  the  temporal 
vessels  are  reached  they  are  doubly  clamped  and  divided  with  the  cautery. 
After  getting  well  under  the  parotid  growth  from  in  front  and  above,  the  cau- 
tery is  pushed  posteriorly,  hugging  the  capsule  of  the  parotid  fairly  closely,  but 
taking  care  not  to  enter  the  capsule.     The  dissection  is  then  carried  down  to 


Fig.   JS4. — The   operation   of    Sedillot   for   excision   of   tlie    tongue. 


the  neck  and  the  external  carotid  is  again  clamped  and  tied  just  below  the  parotid 
and  the  parotid  gland  and  tumor  are  cut  away  with  the  cautery.  Care  should 
be  taken  in  this  latter  step  not  to  'svound  the  internal  jugular  vein. 

If  a  complete  block  dissection  of  the  neck  is  necessary  the  incision  extends 
from  the  zygcma  downward  over  the  anterior  border  of  the  sternomastoid  mus- 
cle and  terminates  in  front  of  the  sternoclavicular  joint.  The  dissection  is  made 
from  below  upward  and  the  parotid  gland  is  dissected  cut  along  with  the  mass 
of  tissue  from  the  neck  in  the  manner  that  has  just  been  described.  The  wound 
is  closed,  placing  a  drainage  tube  through  a  stab  wound  or  at  the  lower  angle 
of  the  incision,  for  drainage  should  always  be  used  after  every  extensive  opera- 
tion for  cancer. 


FACE    AND    MOUTH 


245 


THE  TONGUE 

In  operations  on  the  ton<i'nc  the  head  shonld  be  elevated  and  the  l)est  pos- 
sibh'  liji'lit  obtained.  The  rectal  anesthesia  of  Gwathnny  is  ver,y  desirable,  espe- 
cially if  the  electric  cautery  is  used. 

Benign  tumors  of  the  tongue  are  removed  by  using  the  same  general  prin- 
ciples of  operative  surgery  that  would  be  applicable  in  benign  tumors  else- 
where. There  are,  however,  special  considerations  on  account  of  the  function 
of  tlie  tongue.  In  a  great  enlargement  of  the  tongue  its  size  may  be  reduced  by 
excision   of   a  section   along  its   margin.      The   tongue   is  pulled   forward   hy 


Fig.    285. — Line    of    incision    for    operation    of    Ashhurst    for    excision    of    tlie    tongue. 

a  suture  near  its  middle  and  an  incision  is  made  on  the  dorsal  surface  of  the 
tongue  parallel  to  its  edge,  and  as  far  as  may  seem  necessary  from  the  edge  in 
order  to  remove  a  sufficient  amount.  A  similar  incision  is  made  on  the  under 
surface  of  the  tongue  and  these  two  incisions  are  united  in  a  wedge-shaped 
manner  at  the  posterior  ends  of  the  incisions,  at  the  same  time  making  traction 
on  the  tongue  toward  the  opposite  side  in  order  to  control  bleeding  and  to  ex- 
pose the  tongue  more  readily.  A  wedge-shaped  section  is  thus  removed,  intro- 
ducing sutures  as  it  is  being  excised.     Sutures  of  fine  silver  wire  are  very 


246 


OPERATIVE    SURGERY 


satisfactory  for  wounds  of  the  tongue  and  may  be  so  twisted  as  to  prevent  the 
ends  of  the  wire  from  irritating  the  mucosa  of  the  mouth. 

Benign  localized  tumors  are  removed  by  a  V-shaped  incision.  A  tractor 
suture  is  placed  through  the  tongue  well  behind  the  growth.  A  V-shaped 
section,  including  the  tumor,  is  cut  out  by  a  sharp  electric  cautery.  The  wound 
is  closed  with  fine  silver  wire,  which  is  twisted,  and  the  ends  are  bent  to  prevent 
irritation  of  the  mouth.    Silver  wire  has  many  advantages  as  a  suture  in  this 


Fig.  286. — A  block  dissection  of  the  upper  neck  is  made.      (Ashliurst.) 


region.  It  is  very  slightly  irritating  and  is  mildly  antiseptic.  It  may  be  left 
much  longer  than  any  other  suture  material  without  causing  trouble.  On  ac- 
count of  the  great  mobility  of  the  tongue  the  sutures  should  be  left  in  longer 
than  in  other  regions  and  all  of  them  should  not  be  removed  at  the  same  time 
if  the  wound  is  at  all  extensive.  The  first  silver  wire  suture  may  be  taken  out 
at  the  end  of  about  twelve  days  or  two  weeks  from  the  time  of  operation. 

Complete  excision  of  the  tongue  for  cancer  is  not  so  frequently  done  as 
formerly  because  with  careful  dissection  with  the  electric  cautery  total  removal  is 


FACE   AND    MOUTH 


247 


l'rcM|iu'ully  iiiiiuHTssiiry.  Tlior(>  an*  many  different  operations  for  removal  of 
the  toiif^'ue.  Thai  iiictliod  should  be  chosen  wliicli  a])p(>ars  to  lend  itself  best  to 
the  purposes  of  a  bk)ek  dissection  not  oidy  of  the  tongue  and  its  adjacent  tis- 
sues but  of  the  tissues  of  the  neck.  Dissection  of  the  tongue  with  electric  cau- 
tery is  always  done  wherever  possible,  particularly  in  cancerous  affections,  not 
only  because  it  lessens  bleeding  but  because  it  diminishes  the  chances  of  recur- 


Fig.    2S7. — The   incision    has   been    continued   to    the    cavity   of   the   mouth,    the   flap    has    been    reflected,    and 
excision  of  the  tongue  is  being  completed.      (Ashhurst.) 


rence.    If  there  is  an  ulcerated  lesion  it  should  be  thoroughly  cauterized  as  the 
first  step  in  the  operation  in  order  to  prevent  implantation  of  cancer  cells. 

The  question  of  anesthesia  in  these  cases  is  highly  important.  If  the  cau- 
tery is  to  be  employed  it  is  dangerous  to  use  ether  about  the  face.  The  rectal 
anesthesia  of  Gwathmey  is  excellent  here.  A  malignant  lesion  that  is  sufficient 
to  demand  excision  of  the  tongue  will  also  require  dissection  of  the  neck.  It 
is  best  to  do  this  first  as  it  enables  the  surgeon  to  control  the  blood  supply  of 
the  tongue  by  ligating  the  lingual  or  the  external  carotid  artery,  and  at  the 


248  OPERATIVE    SURGERY 

same  time  it  subjects  the  patient  to  the  dangers  of  inlialation  pneumonia  during 
only  that  portion  of  the  operation  in  whicli  the  mouth  cavit}'  is  entered  to  re- 
move the  tongue. 

According  to  the  method  of  Sedillot,  a  median  incision  is  made  in  the  lower 
lip,  chin  and  neck  as  far  down  as  the  hyoid  bone.  The  lower  jaw  is  divided  with 
a  saw  in  the  midline  and  the  two  halves  of  the  jaw  are  pulled  apart.  The 
tongue  is  pulled  out  with  a  tractor  suture  and  the  mucosa  in  the  floor  of  the 
mouth  is  divided  from  before  backward  (Fig.  284).  If  the  lingual  artery  has 
not  been  previously  tied  during  the  neck  dissection  it  is  recognized  as  lying  be- 
tween the  hyogiossus  and  genioglossus  muscles  and  is  clamped  and  tied.  The 
hyoglossus  and  mucosa  behind  it  are  divided  with  cautery  while  making  trac- 
tion on  the  tongue.  If  the  disease  extends  to  the  palate  or  pharynx  the  affected 
tissue  in  this  neighborhood  is  excised  in  one  mass  if  possible.  The  base  of  the 
tongue  is  divided,  preferably  with  a  cautery,  taking  care  to  preserve  as  much 
muscle  and  as  many  nerves  as  possible  so  as  not  to  interfere  too  greatly  with 
deglutition,  but  at  the  same  time  going  a  reasonable  distance  from  the  cancer. 
The  bone  is  drilled  and  wired  together.  The  patient  is  kept  in  the  Trendelen- 
burg position  until  he  is  able  to  sit  up. 

The  operation  of  A.  P.  C.  Ashhurst  is  designed  to  combine  a  block  dissec- 
tion of  the  neck  with  excision  of  tlie  tongue.  An  incision  is  first  made  from  the 
chin  downward  to  the  hj'oid  bone  and  then  backward  to  the  tip  of  the  mastoid 
process  (Fig.  285).  The  lower  edge  is  retracted  and  the  upper  portion  of  the 
neck  is  cleared  with  a  block  dissection  from  below  upward  leaving  the  tissues 
attached  to  the  upper  skin  flap.  The  dissection  extends  from  below  the  bifur- 
cation of  the  common  carotid  to  the  floor  of  the  mouth.  It  reaches  the  muscles 
of  the  neck  and  the  hypoglossal  and  superior  laryngeal  nerves  (Fig.  286). 
The  neck  wound  is  packed  with  gauze  and  the  anterior  end  of  the  incision  is 
prolonged  through  the  midline  of  the  lower  lip  into  the  mouth.  This  forms  a 
flap  which  is  dissected  backward,  so  exposing  the  tongue.  The  tissue  of  the 
block  dissection  of  the  neck  is  then  cut  away  from  this  flap.  The  tongue  is 
held  forward  by  a  tractor  suture.  The  mucous  membrane  between  the  lip  and 
the  lower  jaw  is  divided  with  scissors  or  cautery  from  before  backward.  The 
masseter  muscle  is  not  cut.  Another  tractor  suture  is  now  passed  through  the 
glosso-epiglottidean  fold,  which  facilitates  drawing  the  tongue  forward.  The 
frenum  of  the  tongue  is  divided  and  the  dissection  continued  backward  on  the 
other  side  of  the  tongue,  separating  the  tongue  from  the  floor  of  the  mouth,  first 
on  the  side  opposite  to  the  disease  and  then  on  the  diseased  side  (Fig.  287). 
The  anterior  pillow  of  the  fauces  is  divided  on  both  sides,  the  tongue  is  draAvn 
well  out.  It  is  cut  across  at  its  ba^e  at  least  three-fourths  of  an  inch  beyond 
the  visible  signs  of  cancer  on  the  diseased  side  and  then  on  the  health}^  side 
backward  along  the  floor  of  the  mouth  to  the  transverse  section  of  the  diseased 
side.  The  lingual  artery  on  the  healthy  side  is  watched  for  and  caught.  The 
tongue  is  then  completely  cut  across  and  the  stump  of  the  tongue  is  sutured  to 
the  mucosa  that  may  still  be  remaining  on  the  inner  side  of  the  alveolar  process 
of  the  lower  jaw  or  from  the  inner  side  of  the  cheek.     "Wherever  possible  the 


FACK    AND    MOUTH 


249 


raw  sui'fai'O  is  roveri'd  by  niiu'o.sa.  After  tlie  eonipletion  of  the  operation  a  few 
buried  sutures  attaeli  the  cheek  to  the  body  of  the  jaw.  The  skin  wound  is 
accurately  closed  and  a  i-ubber  drainage  tube  is  inserted  at  the  most  dependent 
portion  of  the  external  ineisioii.  Ashhurst'^  advises  the  removal  of  all  the  molar 
teetli  on  llie  diseased  side  of  the  tongue  before  the  wound  is  sutured  as  well  as 
the  (.'orresponding  alveolar  process  of  the  lower  jaw  if  it  seems  at  all  likely  that 
this  has  been  affected  by  the  cancer. 

The  method  of  excision  of  the  tongue  practiced  by  Blair'^  is  well  conceived 
and  will  probably  replace  other  operations  for  advanced  cancer  of  the  tongue. 


M 

.^^mmm.'. 

V 

P 

.^^^^m" 

1 

I 

t 

>- 

^--.. 

v^nMl 

^ 

-%-'.  ' 

He\e-T^    loorxainne 

2.0 

Fig.   288.- 


-Line    of   incision    in    operation    of    \.    P.    Blair    for    excision    of    tongue    in    advanced    cancer.      A 
tracheotomy   had  been  done  several  days  previously. 


He  advises  a  low  tracheotomy,  preferably  done  under  local  anesthesia  one  or 
two  days  before  the  operation  on  the  tongue  (Fig.  288).  The  incision  begins 
behind  the  angle  of  the  jaw,  curves  do\\aiward  to  just  below  the  lower  border 
of  the  hj'oid  bone  in  the  midline,  and  is  carried  upward  behind  the  angle  of 
the  jaw  on  the  other  side  of  the  neck  to  a  point  corresponding  with  its  begin- 
ning. The  incision  is  carried  through  the  platysma  muscle  and  the  npper  flap, 
consisting  of  skin  and  platysma,  is  dissected  from  the  deep  cervical  fascia  to 
the  lower  border  of  the  jaAv.    The  facial  vessels  at  the  lower  border  of  the  jaw 


^Ashhurst,  A.  P.   C:     Ann.  Surg..   1915.  Ixii,   238-245. 

^Blair,   V.   P.:      Surg.,   Gynec.   &  Obst.,   February,   1920,   pp.   149-153. 


250 


OPERATIVE    SURGERY 


are  doubly  clamped  and  divided.  The  facial  vein  is  doubly  clamped  and  divided 
on  the  level  with  the  skin  incision.  The  submaxillary  gland  is  drawn  upward 
and  the  facial  arterj^  is  doubly  clamped  and  divided  just  as  it  enters  the  gland 
and  as  far  as  possible  from  its  origin  (Fig.  289).  The  artery  is  tied  and  the 
branches  within  half  an  inch  of  its  end  are  also  tied.  Blair  thinks  it  is  impor- 
tant to  leave  a  long  stump  of  the  facial  artery  with  its  branches  ligated  in  order 


Fig.   289. — The  dissection   of  the  neck  is  begun  and  the   facial  vessels  are   doubly   clamped   and   divided. 


to  prevent  secondary  hemorrhage.  The  submaxillary  gland  with  its  surrounding 
tissue  is  dissected  out.  Behind  the  upper  and  outer  part  of  the  digastric  ten- 
don the  fibers  of  the  hyoglossus  muscle  are  separated  bluntly  and  the  lingual 
artery  is  exposed  and  tied.  The  submaxillary  gland  with  its  surrounding  tissue 
having  been  removed  on  each  side  and  the  blood  controlled,  the  muscles  beneath 
the  symphysis  are  divided  with  a  sharp  electric  cautery.  The  periosteum  and  mu- 
cous membrane  are  stripped  from  the  inner  surface  of  the  jaw  and  the  cancer,  if 
an  ulcer,  is  thoroughly  cauterized.     The  tongue  is  drawn  through  the  open- 


FACE   AND    MOUTH 


151 


por- 
The 


iiig  beneath  tlie  symphysis  of  the  lower  jaw.  This  exposes  the  pharynx.  The 
tongue  is  severed  Avith  an  electric  cauterj-  at  the  hyoid  bone.  The  lower 
tion  of  each  parotid  gland  is  also  removed,  preferably  with  the  canter5^ 
lower  border  of  the  digastric  muscle  on  each  side  is  sutured  to  the  sterno- 
mastoid  muscle  witli  fine  tanned  catgut.  The  stumps  of  the  facial  artery  are 
left  standing  out  fi'eo  into  the  pharynx.     By  having  a  long  stump  and  tying 


Fig.    290. — Operation   of   Blair   completed,    except   suturing   the   wound. 


the  little  branches  there  is  rarely  secondary  bleeding  from  the  facial  (Fig.  290). 
For  feeding  purposes  a  catheter  is  passed  through  one  nostril  into  the  pharynx 
and  fastened  to  the  upper  lip  by  adhesive  plaster  or  a  suture.  This  is  done 
before  the  wound  is  closed  as  the  larynx  drops  back  after  the  operation  and 
makes  it  more  difficult  to  pass  the  catheter  into  the  esophagus.  The  wound 
is  closed  with  silkworm-gut.  The  tracheotomj^  tube  is  left  in  for  a  week  or  ten 
days  until  danger  of  edema  of  the  larynx  is  passed.  The  day  before  its  removal 
it  is  plugged  with  a  cork  to  test  whether  the  patient  can  breathe  satisfactorily 
through  the  larvnx. 


252 


OPERATIVE    SURGERY 


UPPER  JAW 

If  a  growlli  is  IJiniU'd  to  the  alveolar  proeess  it  may  be  removed  by  first 
cutting-  the  mucosa  and  stripping  it  back  to  the  point  at  which  the  section  of  the 
bone  is  to  be  made.  The  bone  is  removed  by  a  small  sharp  chisel  or  a  small  finger 
saw,  Schlange's  method  is  to  drive  several  gouges  in  the  proposed  line  of  re- 
section of  the  alveolus  and  leave  them  in  position  to  control  hemorrliage  until 
the  last  gouge  is  driven  in  to  separate  the  final  attachment.  Then  the  wound 
is  quickly  packed.  If  a  solution  of  epinephrin  is  injected  into  the  mucosa  be- 
fore the  incision  is  made  the  bleeding  is  greatly  diminished  and  the  operation 
is  facilitated. 


Fig.   291. — lanes    of  incision    for   operation   of   Weber   for   excision    of  upper   jaw. 

Excision  of  the  upper  jaw  is  done  for  malignant  tumors.  A  number  of 
incisions  have  been  devised  as  it  was  a  standard  operation  of  preantiseptic  days. 
Probably  the  most  satisfactory  incision  for  excision  of  the  upper  jaw  is  Weber's, 
This  begins  at  the  inner  canthus  of  the  eye,  goes  downward  in  the  groove  be- 
tween the  nose  and  cheek,  skirts  the  ala  of  the  nose,  curves  inward  to  the  mid- 
line of  the  upper  lip  and  divides  the  upper  lip  vertically  (Fig.  291).  From 
the  upper  extremity  of  the  incision  a  slightly  curved  cut  is  made  outward 
following  the  lower  margin  of  the  orbit.  The  flap  is  reflected  outward  and 
the  superior  maxillary  bone  is  exposed.  Unless  the  indications  of  the  operation 
demand  it,  it  is  best  to  leave  the  orbital  plate  of  the  superior  maxillae,  but 
if  this  cannot  be  safely  preserved  the  periosteum  should  be  stripped  up  and 
the  orbital  contents  lifted  gently  upAvard  and  outward  with  a  retractor.     The 


FACE    AND    lAIOUTH 


253 


malar  bone  is  dixidcd  with  roi'('('])s  oi-  a  wire  saw,  and  tlion  tlic  nasal  and  orl)i- 
tal  processes  of  the  snix'rioi-  maxilla  arc  (li^■id('d  <d  the  inner  and  lower 
portion  of  the  orbit.  The  mouth  is  opened  and  an  ineision  is  made  in  the 
hard  palate  alonu'  the  midline  or  parallel  to  it.  The  middle  incisor  teeth  are 
removed  and  with  a  finger  saw  the  hard  palate  and  alveolar  process  arc  divided 
from  within  the  nostril.  The  soft  palate  is  separated  from  the  hard  palate  with 
i-cissors.  The  superior  maxilla  is  then  seized  with  heavy  forceps  and  bent  out- 
ward and  with  a  twisting  motion  is  removed,  cutting  any  attached  strands  of  tis- 
sue. The  cavity  caused  by  its  removal  is  at  once  packed  with  dry  gauze  which  is 
firmly  pressed  in  position  and  held  for  four  or  five  minutes.  It  is  gradually 
removed  and  any  bleeding  spots  that  can  be  clamped  are  caught  and  tied.     The 


Fig.  292. — Lines  of  incision  for  operation  of 
Binnie  for  excision  of  the  upper  jaw  when  tlie 
skin    is   involved. 


Fig.  293. — Reflection  of  flap  in  operation  of  Binnie 
for   excision   of   upper  jaw. 


wound  is  packed  with  iodoform  gauze  and  the  reflected  flap  is  sutured  into 
position.  Multiple  ligations  of  the  external  carotid  artery  before  excising  the 
jaw  lessen  bleeding  and  probably  decrease  recurrence. 

The  patient  is  put  to  bed  with  the  head  turned  toward  the  operative  side 
and  the  wound  in  the  mouth  is  kept  clean  by  frequent  spra^dng  with  mild 
antiseptic  solutions  or  by  irrigating  it  with  the  patient  turned  in  such  a  posi- 
tion that  the  fluid  readily  runs  out. 

If  the  growth  in  the  upper  jaw  involves  the  skin  the  incision  of  "Weber 
cannot  be  satisfactorily  applied.  An  excellent  incision  for  cases  of  this  type 
is  that  of  Binnie.  According  to  his  method  incisions  are  made  around  the 
tumor  in  healthy  skin  as  close  to  the  growth  as  is  thought  wise.  The  upper 
junction   of  these  incisions   is   joined   b}"   another   incision   that   begins   at   the 


254  OPERAxnrE  surgery 

nose  just  below  the  inner  angle  of  the  eye  and  from  the  lower  junction  an  in- 
cision goes  almost  to  the  angle  of  the  mouth  (Fig.  292).  The  flap  with  the 
nose  and  upper  lip  as  base,  is  dissected  and  retracted  inward  and  the  outer 
incisions  around  the  growth  are  undercut  and  retracted  outward  (Fig.  293). 
The  bone  is  then  removed  in  the  same  manner  as  described  after  the  incision 
of  AYeber. 

In  squamous  cell  cancer  involving  the  eye  and  upper  jaw  frequently  a  typi- 
cal operation  cannot  be  done.  The  growth  should  first  be  cauterized  thoroughly 
with  a  thermocautery  and  circumscribed  with  an  incision  a  safe  distance  from 
the  margin  of  the  cancer.  Dissection  is  then  made  to  remove  the  neoplasm  and 
the  tissues  immediately  around  it  in  one  mass  so  far  as  possible.  The  raw 
surface  remaining  should  then  be  cauterized  with  a  thermocautery  and  the 
plastic  operation  that  may  be  indicated  is  undertaken  at  some  subsequent 
time  after  the  sloughs  have  separated. 

A  temporary  osteoplastic  resection  of  the  upper  jaw  in  order  to  gain  access 
to  a  tumor  in  the  pharynx  can  be  done  much  along  the  same  line  as  indicated 
in  the  TVeber  operation  excej^t  that  the  jaw  bone  is  left  attached  to  the  flap 
and  is  reflected  along  with  the  flap.  After  the  operation  has  been  completed 
the  flap  with  its  attached  bone  is  replaced.  In  this  operation  it  is  not  necessary 
to  remove  the  lower  plate  of  the  orbit  which  is  separated  from  the  rest  of  the 
superior  maxilla  by  a  sharp  chisel. 

LOWER  JAW 

Tumors  of  the  lower  jaw  along  the  alveolar  process  may  be  removed  in  the 
same  manner  as  similar  tumors  of  the  alveolar  process  of  the  upper  jaw.  The 
lower  jaw  is  somewhat  more  accessible  than  the  upper  jaw  and  often  permits 
the  use  of  a  small  rotar}-  saw  which  greatly  facilitates  the  operation.  Holes  may 
be  drilled  in  the  proposed  line  of  incision  and  the  section  of  bone  removed  with 
a  small  thin  chisel.  In  growths  that  spring  from  the  sockets  of  the  teeth  it 
is  necessary  to  destroy  or  remove  the  lining  of  the  tooth  socket,  else  a  recur- 
rence is  probable.  This  can  sometimes  be  done  by  the  point  of  a  sharp  electric 
cautery  and  may  prevent  a  loss  of  considerable  bone  substance. 

In  resection  of  one-half  of  the  inferior  maxilla  an  incision  may  be  made 
as  described  in  the  Ashhurst  operation  for  excision  of  the  tongue.  The  lower  jaw 
can  usually  be  removed,  however,  by  a  less  extensive  incision,  which  begins 
at  the  chin,  goes  downward  and  backward  just  below  the  lower  border  of  the 
jaw.  and  then  curves  slightly  upward  behind  the  angle  of  the  jaw.  The  facial 
artery  is  clamped,  divided  and  ligated.  The  amount  of  tissue  that  should  be 
removed  along  with  the  lower  jaw  depends  upon  the  indication  for  the  opera- 
tion. If  the  cancer  presents  a  raw  surface  within  the  mouth  this  should  be 
thoroughly  cauterized  with  a  thermocautery  before  making  an  incision.  The 
soft  tissues  are  loosened  from  their  attachments  along  the  margins  of  the  incision 
and  the  middle  lower  incisor  teeth  are  extracted.  The  bone  is  divided  in  the 
midline  or  at  the  point  desired  by  a  wire  saw  after  the  soft  parts  have  been 


FACE   AND    MOUTH 


255 


separalinl  in  tliis  I'ciiion  and  proti'ded  from  the  saw.  Tlic  bone  is  pulled  down- 
ward and  outward  and  its  attachments  to  the  muscles  and  to  the  mucosa  are 
separated  from  before  backward.  The  coronoid  process  is  divided  unless  it  is 
distinctly  involved  in  the  growth  and  the  masseter  muscle  and  the  parotid 
gland  are  dissected  from  the  ramus  of  the  jaw.  The  head  of  the  bone  is  torn 
from  its  articulation  vs'ith  a  twisting  motion.  Bleeding  points  are  tied  and 
the  mucosa  within  the  mouth  is  approximated  if  possible.  Drainage  with  a 
tube  in  a  stab  wound  is  provided.  The  after-treatment  is  similar  to  that  after 
excision  of  the  upper  jaw. 

Partial  resections  of  the  jaw  may  be  indicated  for  malignancy  of  the  jaw 
itself  or  for  cancer  of  the  floor  of  the  mouth.  When  cancer  involves  the  floor 
of  the  mouth  and  under  surface  of  the  tongue  a  free  dissection  of  the  floor  of 
the  mouth  is  essential  to  cure.  If  provision  is  not  made  for  a  resection  of  a 
part  of  the  lower  jaw  the  resulting  wound  is  difficult  to  heal.     It  is  best  to  re- 


K^ 


Fig.  294. — Operation  of  V.  P.  Blair  for  cor- 
rection of  retracted  chin.  The  first  incision  has 
been  made  and  a  silk  ligature  is  passed,  to  which 
a  wire  saw  will  be  fastened. 


Fig.    295. — The   line    of   incision    of   the    lower   jaw 
is  shown. 


sect  a  portion  of  the  jaw  to  permit  the  jaw  bone  to  collapse  at  this  point  until 
healing  has  occurred.  Later  the  tissues  may  sometimes  be  stretched  and  a 
plastic  operation  with  transplantation  of  bone  is  occasionally  possible.  The 
bone  is  divided  in  the  midline,  as  though  a  resection  of  one-half  of  the  inferior 
maxilla  were  to  be  done.  The  tissues  are  divided  with  electric  cautery  keeping 
close  to  the  bone  and  making  a  block  dissection  as  far  as  possible.  That  por- 
tion of  the  inferior  maxilla  to  which  the  growth  is  nearest  is  removed  along 
with  the  growth,  dividing  the  bone  with  a  wire  saw.  This  permits  the  space 
in  the  floor  of  the  mouth  to  collapse  and  healing  takes  place  more  readily  than  if 
the  bone  were  kept  intact.  The  principle  is  the  same  as  that  of  multiple  ex- 
cision of  the  ribs  in  chronic  empyema. 

After  excision  of  either  the  upper  or  the  lower  jaw  a  competent  dentist 
should  be  consulted  so  he  can  provide  the  proper  prosthetic  devices  to  prevent 
deformity  as  far  as  possible. 


256  OPERATIVE   SURGERY 

Blair  has  developed  operations  for  correction  of  deformities  of  the  lower 
jaw.  When  there  is  marked  retraction  of  the  chin  from  lack  of  development 
of  the  bone  he  divides  the  bone  throngh  an  incision  about  three-fourths  of  an 
inch  long  through  the  skin  over  the  posterior  border  of  the  lower  jaw  in  front 
of  the  lobe  of  the  ear.  The  parotid  sheath  is  opened  at  the  anterior  border  of 
the  gland  and  the  gland  is  drawn  backward  until  the  posterior  border  of  the 
ramus  of  the  jaw  can  be  felt.  A  curved  pedicle  needle  with  the  eye  at  the 
end  and  threaded  with  heavy  silk,  is  passed  through  this  incision  between  the 
parotid  gland  and  the  masseter  muscle,  going  behind  the  ramus  of  the  jaw  and 
hugging  the  bone  closely.  The  point  of  the  needle  emerges  through  the  skin 
of  the  cheek  in  front  of  the  ramus  of  the  jaw  without  penetrating  the  mucosa 
of  the  mouth  (Fig.  294).  The  silk  is  withdrawn  and  fastened  to  the  end  of 
a  wire  saw  which  is  pulled  through  and  which  divides  the  ramus  of  the  jaw 
horizontally   (Figs.  295  and  296).     The  hemorrhage  is  controlled  by  packing 


Fig.  296. — The  ramus  of  the  lower  jaw   is  completely  divided  and  the  jaw  is   brought  forward  and   fastened 
in  its  corrected  position   by  wires   to   the   teeth. 

the  wound  with  gauze.  A  similar  procedure  is  carried  out  on  the  other  side 
and  the  teeth  of  the  lower  jaw  are  wired  to  the  teeth  of  the  upper  jaw  in  such 
a  position  as  will  insure  satisfactory  articulation  and  forward  advancement  of 
the  lower  jaw.  It  will  be  necessary  to  stretch  the  muscles  considerably  in  order 
to  accomplish  this. 

If  the  jaw  is  too  long,  sections  may  be  removed  from  each  side  near  the 
angle  of  the  jaw  and  the  bone  reunited  by  sutures  through  drill  holes  that  have 
been  made  previously  to  the  resection  of  the  bone.  Such  operations  should  only 
be  undertaken  with  the  cooperation  of  a  good  dentist  who  is  interested  in  this 
work. 

In  ankylosis  of  the  temporomaxillary  joint,  the  head  of  the  bone  on  the 
affected  side  may  be  resected  if  it  has  been  determined  that  the  ankylosis  is 
dependent  upon  this  joint.  The  operation  described  by  Murphy,  or  some 
modification,  is  satisfactory.  It  must  first  be  ascertained  which  side  is  affected. 
This  can  usually  be  done  by  careful  observation  and  noting  that  there  is  a 


FACE    AND    .MOI  'III 


257 


slight  slitliiig  motion  forward  of  the  jaw  hoiir  on  tln'  uiiatrceted  side  as  tlie  pa- 
tient attempts  to  ojkmi  liis  mouth.  The  muscles  on  the  ankylosed.  side  are 
usually  moi-(^  atrophied  than  on  the  nnattVeted  sid(\  The  operation  of  J.  B. 
Murphy  is  done  through  an  L-shaped  incision  which  begins  in  the  temporal 
region  above  and  in  front  of  the  ear  and  goes  downward  to  the  posterior  portion 
of  the  zygoma,  curves  forward  along  the  upper  border  of  the  zygoma  for  about 
three-fourths  of  an  inch  and  then  goes  slightly  upward  so  as  to  avoid  the 
branch  of  the  facial  nerve  (Fig.  297).  This  flap  of  skin  and  fascia  is  reflected 
upward  and  the  iieck  of  the  condyle  of  the  lower  jaw  is  exposed.  ]\Iurphy  uses 
special  reti'actors  for  this  puri)0se.     The  internal  maxillary  artery  passes   in- 


Fig.  297 


-The  lines  of  incision  and  the  outline   of  the  bony  skeleton  for  approach  to   the  temporomaxillary 
joint  according  to  J.   B.   !Murphy. 


ward,  behind  the  neck  of  the  condyle  of  the  lower  jaw  and  close  to  the  bone,  and 
it  is  necessary  to  protect  this  vessel  by  small,  deep  retractors.  The  neck  of 
the  bone  is  divided  with  a  wire  saw  and  a  half-inch  section  of  bone  is  removed. 
This  may  be  done  with  forceps  or  a  chisel  instead  of  a  saw.  A  flap  of  fat  and 
fascia  from  the  temporal  muscle  is  then  dissected  with  the  base  downward  and 
is  tucked  in  between  the  divided  ends  of  the  neck  of  the  condyle  and  securely 
fastened  in  this  position  by  buried  sutures  of  tanned  catgut. 

The  disadvantages  of  ]Murpliy's  operation  are  that  in  jDrolonged  ankylosis 
the  muscles  are  frequently  contracted  or  atrophied  so  that  even  after  division 
of  the  bone  it  is  difficult  for  function  to  be  reestablished.  "When  the  tissue 
changes  about  the  joint  and  the  coronoid  process  are  extensive,  operations  on 


258  OPERATIVE    SURGERY 

the  temporomaxillary  joint  alone  will  not  avail.  Here  the  operation  often 
known  as  Esmarch's  operation,  in  which  a  triangle  of  bone  is  removed  from  the 
lower  jaw  near  its  posterior  angle,  gives  excellent  results.  In  this  operation 
an  incision  about  two  and  one-half  or  three  inches  long  is  made,  beginning  just 
above  the  lower  angle  of  the  jaw  and,  extending  along  its  lower  border.  This 
is  made  while  drawing  the  skin  upward  so  that  the  scar  will  not  be  conspicuous. 
The  facial  artery  is  divided  or  retracted.  The  soft  parts  are  separated  from 
the  bone  on  the  inner  and  outer  surface.  The  periosteum  is  divided  along  the 
proposed  lines  of  the  resection  and  a  triangular  or  wedge-shaped  piece  of  bone 
having  its  apex  at  the  posterior  portion  of  the  alveolar  process  is  removed  with 
a  rotary  saw  or  a  wire  saw.  The  base  of  the  wedge  which  is  just  in  front  of 
the  angle  of  the  jaw  is  about  one  and  one-fourth  inches  long  (Fig.  298).  In 
a  child  the  base  of  the  wedge  would  be  proportionately  less.     When  the  bone 


Fig.   298. — Lines  showing   the   excision   of  bone  for  the   Esmarch   operation. 

is  resected  the  inferior  dental  artery  and  nerve  are  divided.  Hemorrhage  is 
controlled  by  packing  or,  if  necessary,  by  the  application  of  bone  wax.  A 
flap  of  tissue  from  the  masseter  muscle  may  be  sutured  in  the  defect  in  order 
to  prevent  bony  union.  The  wound  is  closed  without  drainage.  Care  is  taken 
to  avoid  wounding  the  mucosa  of  the  mouth. 

PERIPHERAL  OPERATIONS  ON  THE  FIFTH  NERVE 

Neuralgia  of  the  trifacial  nerve  may  require  operation  for  resection  of  its 
peripheral  branches.  It  is  probably  true  that  in  genuine  tic  douloureux  peripheral 
operations  or  injections  of  alcohol  are  never  permanently  curative.  However, 
they  may  give  relief  for  several  years  and  if  the  patient  desires  this  type  of 
operation  with  the  assurance  that  it  will  in  all  likelihood  not  be  a  permanent  cure 
it  should  be  done.  Peripheral  resection  of  the  supraorbital  branch  of  the  tri- 
facial nerve  can  be  done  through  an  incision  in  the  eyebrow,  which  leaves  no 
disfiguring  scar.  The  nerve  is  exposed,  grasped  with  forceps,  and  firm  and 
steady  traction  is  made  continuously  by  slowly  twisting  over  the  forceps,  and 
the  nerve  is  extracted.  In  this  way  a  considerable  length  of  the  nerve  is  removed. 
The  foramen  from  which  the  nerve  has  been  removed  is  plugged  with  a  piece 
of  neighboring  periosteum  or  soft  tissue  which  is  packed  into  the  foramen  with 


FACE   AND    MOUTH 


259 


the  oiul  of  a  probe.    A  luelal  screw  or  irritating  foreign  substances  should  never 
be  used  to  occlude  a  foramen  fi-oni  which  a  nerve  has  been  removed. 

Operations  ui^on  tlie  second  or  superior  maxillary  division  of  the  fifth 
nerve  can  best  be  done  within  the  mouth.  An  external  incision  is  unnecessary 
and  is  very  disfiguring.  The  lip  and  outer  angle  of  the  mouth  are  forcibly 
retracted  upward  and  a  weak  solution  of  epinephrin  is  injected  freely  into 
the  mucous  membrane  and  tissues  around  the  infraorbital  foramen.  A  trans- 
verse incision  of  about  one  and  one-fourth  inches  is  made  through  the  mu- 
cosa where  it  is  reflected  from  the  bone  to  the  inner  surface  of  the  cheek. 
This  incision  is  carried  down  to  the  bone.  The  periosteum  is  elevated  with  a 
periosteal  elevator  up  to  the  region  of  the  infraorbital  foramen.     This  point 


..*^.-^  K?^=,, 


H  \^    \  V^    V"'' 


Fig.    299. — Incision   for   resection   of   second   division   of   the   fifth    nerve    from   within   the   mouth. 


is  marked  by  the  finger  on  its  approximate  location  just  below  the  loAver 
eyelid.  AVhen  the  foramen  is  seen  the  periosteum  is  stripped  up  freely  around 
it  and  the  nerve  is  recognized  emerging  from  the  foramen  (Fig.  299).  The 
nerve  is  caught  with  a  pair  of  hemostatic  forceps  and  gradual  traction  is  made 
over  a  period  of  several  minutes. 

Two  inches  or  more  of  the  nerve  can  be  extracted  in  this  way.  The  fora- 
men is  plugged  with  a  piece  of  neighboring  periosteum.  The  incision  in  the 
mucosa  is  sutured.  A  gauze  compress  is  placed  over  the  cheek  and  fastened 
firmly  for  twenty-four  hours  in  order  to  prevent  oozing  and  swelling. 

The  third  division  of  the  fifth  nerve  is  more  difficult  to  reach  but  can  be 
operated  upon  from  within  the  mouth.     The  mucous   membrane   and   tissue 


260  OPERATIVE    SURGERY 

over  it  in  the  region  of  the  proposed  incision  are  infiltrated  with  a  weak  solu- 
tion of  epinephrin.  An  incision  about  one  inch  long  is  made  internal  to  and  paral- 
lel with  the  anterior  border  of  the  ascending  ramus  of  the  lower  jaw,  the  mouth 
being  held  well  open  with  a  gag.  The  periosteum  is  stripped  up  from  the 
bone  until  the  inferior  dental  spine  is  felt  and  the  ligament  of  the  jaw  which 
is  attached  to  this  spine  is  divided  with  scissors.  The  nerve  is  just  behind 
this  and  is  hooked  up  into  the  wound  and  as  much  of  it  as  possible  is  removed 
bv  gradual  traction. 


CHAPTER  XV 
OPERATIONS  ON  THE  SCALP,  SKULL  AND  BRAIN 

Operations  on  the  scalp,  independent  of  incisions  of  the  scalp  as  a  pre- 
liminary step  in  operations  on  the  brain,  are  not  often  indicated  except  as  a 
result  of  trauma  or  for  benign  tumors.  Injuries  of  the  scalp  are  frequent. 
They  are  treated  by  immediate  disinfection  and  if  the  wound  is  a  ragged  one  it 
is  excised  and  the  margins  are  sutured.  Shaving  or  closely  clipping  the  hair 
in  the  region  of  the  wound  should  always  be  done  as  a  first  step.  The  scalp 
presents  a  somewhat  peculiar  structure  which  renders  the  approximation  of  its 
wounds  or  the  ligation  of  its  blood  vessels  different  from  ordinary  tissues.  The 
skin  of  the  scalp  is  thicker  than  in  other  parts  of  the  body  and  is  intimately 
adherent  to  the  superficial  fascia  which  attaches  it  firmly  to  the  aponeurosis  and 
muscle  just  beneath  it.  This  aponeurotic  layer  of  fascia,  called  the  galea 
aponeurotica,  covers  the  vertex  of  the  skull  and  connects  the  muscular  portions 
of  the  occipitofrontalis  muscle.  It  is  also  continuous  with  the  temporal  fascia 
below  the  temporal  ridge.  It  is  in  reality  a  deep  fascia,  though  it  is  peculiarly 
firmly  attached  to  the  skin.  The  edges  of  the  wound  in  the  scalp  which  do  not 
involve  the  galea  do  not  retract.  The  blood  vessels  run  in  the  deep  layers  of  the 
skin  and  lie  in  very  dense  tissue  to  which  they  are  adherent.  It  is  difficult  to 
pick  up  the  vessels  in  the  scalp  and  bleeding  is  arrested  by  sutures  which  are 
tied  tightly  enough  not  only  to  approximate  the  tissues  but  to  control  bleeding. 
If  the  galea  is  wounded  it  is  necessary  to  include  this  in  the  sutures.  Infec- 
tion of  the  space  of  tissue  beneath  the  galea  and  between  this  fascia  and  the 
pericranium  is  dangerous,  as  the  tissue  here  is  loose  and  infection  may  spread 
rapidly.  A  large  hematoma  can  collect  between  the  galea  and  the  pericranium. 
The  pericranium  is  tightly  attached  to  the  sutures  of  the  skull,  but  adheres 
very  lightly  to  the  surface  of  the  bone  elsewhere  so  that  infection  beneath  the 
pericranium  will  probably  be  limited  to  one  bone  of  the  skull  wdiereas  infection 
between  the  pericranium  and  the  galea  aponeurotica  can  spread  over  the 
whole  scalp. 

In  approximating  wounds  of  the  scalp  it  is  highly  important  to  unite  the 
galea  accurately  in  order  to  obtain  a  satisfactory  adjustment  of  the  scalp  wound. 
If  the  galea  is  not  united  the  wound  will  gap  and  union  of  the  scalp  will  be 
unsatisfactory.  If  the  galea  is  united  the  margins  of  the  skin  of  the  scalp  will 
fall  so  close  together  that  frequently  no  other  sutures  are  required.  In  incising 
the  scalp  in  surgical  operations,  instead  of  grasping  the  individual  vessels,  which 
has  been  explained  as  being  difficult  without  damage  to  the  skin,  the  galea  is 
seized  among  the  margins  of  the  incision  with  long  heavy  hemostatic  forceps 
and  the  forceps  are  turned  outward  and  held  out  of  the  operative  field.     They 

261 


262  OPERATIVE   SURGERY 

will  thus  serve  to  draw  the  galea  up  and  so  compress  the  divided  vessels  in 
the  skin  of  the  scalp  that  complete  temporary  hemostasis  is  obtained.  When 
the  operation  is  completed  permanent  hemostasis  is  secured  by  sutures. 

Sebaceous  cysts  of  the  scalp  are  common.  They  sometimes  grow  to  a  con- 
siderable size  and  are  called  "wens."  They  are  easily  excised  by  a  straight 
incision,  or  by  an  elliptical  incision  which  includes  an  oval  mass  of  the  thin 
redundant  skin.  The  sac  is  removed  by  blunt  dissection,  inserting  closed  scis- 
sors along  the  outer  surface  of  the  cyst  wall,  hugging  it  closely  and  opening 
the  scissors  widely  each  time  after  they  are  inserted.  If  the  cyst  has  been 
wounded  its  edges  are  grasped  with  hemostatic  forceps  and  the  cyst  is  lifted 
out.  All  of  the  cyst  wall  must  be  removed,  otherwise  there  wnll  probably  be  a 
recurrence. 

A  cirsoid  aneurism  of  the  scalp  is  an  enlargement  of  the  normal  arteries 
together  Avith  a  growth  of  new  arteries.  It  is  treated  most  satisfactorily  by  li- 
gation and  excision.  The  vessels  are  ligated  in  what  appears  to  be  a  normal 
area.  If  the  growth  is  not  too  large  excision  can  then  be  attempted.  It  has 
been  suggested  to  follow  the  method  of  Wyeth  of  injecting  hot  water  by  iso- 
lating the  main  trunk  of  the  vessels,  ligating  the  central  end,  and  injecting  into 
the  distal  end  hot  water,  which  will  destroy  the  endothelial  lining  of  the  vessels. 
Of  course,  caution  is  necessary  to  isolate  the  other  branches  from  the  main 
trunk  so  that  the  hot  water  will  course  as  far  as  possible  through  the  region 
of  the  cirsoid  aneurism.  If  the  temporal  arteries  can  thus  be  isolated  this 
operation  has  something  to  commend  it,  but  the  farther  the  point  of  injection 
of  hot  water  is  from  the  origin  of  the  abnormal  vessels,  the  more  danger  there 
is  of  injuring  healthy  tissue.  Of  course,  this  should  never  be  tried  if  the 
healthy  vessels  cannot  be  reached  lower  than  the  upper  portion  of  the  external 
carotid  artery. 

Excision  of  small  angiomas  or  affected  areas  of  the  scalp  is  done  on  general 
surgical  principles,  suturing  the  wound  in  due  regard  to  the  peculiar  structures 
of  the  scalp  that  have  already  been  discussed. 

Operations  upon  the  skull  are  seldom  indicated  except  as  the  skull  may 
be  involved  in  extension  of  a  lesion  from  the  scalp  or  more  frequently  in  order 
to  gain  access  to  the  brain.  As  all  operations  upon  the  brain  except  in  very 
young  infants  require  opening  of  the  skull  this  operation  is  described  as  an 
essential  preliminary  part  of  operations  upon  the  brain.  The  older  method  of 
trephining  in  which  a  button  of  bone  was  removed  from  the  skull  by  a  tre- 
phine, is  but  seldom  used.  If  a  lesion  of  the  brain  is  extensive  enough  to 
demand  an  operation,  it  usually  requires  much  wider  exposure  than  can 
be  obtained  through  a  trephine.  Besides,  in  the  use  of  a  large  trephine  there 
is  danger  of  injuring  the  dura  because  of  the  irregular  thickness  of  the  skull, 
which  might  render  the  skull  at  one  part  of  the  trephine  opening  consid- 
erably thinner  than  at  another  portion.  Opening  the  skull  with  a  mallet  and 
chisel  inflicts  an  unnecessary  amount  of  trauma  upon  the  brain,  which  is 
already  diseased   or  no   operation  would  be  indicated.     The   most   satisfac- 


SCALP,    SKULL,    AND   BRAIN  263 

tory  method  is  tlirouiili  a  hole  drilled  by  a  burr  of  such  construction  that, 
like  the  Hudson  instrument,  it  stops  automatically  when  the  dura  is  reached; 
or  a  burr  of  conical  or  spherical  shape  that  goes  through  the  skull  first 
at  the  central  point  can  be  used.  Here  the  thin  margins  of  bone  next  to  the 
point  of  penetration  are  removed  by  a  sharp-pointed  elevator  and  the  dura  is 
separated  from  the  bone  in  the  region  of  this  opening  by  a  dural  elevator  or  a 
bent  probe.  The  opening  is  enlarged  with  rongeur  forceps,  or  with  forceps 
of  the  DeVilbiss  type,  which  cut  a  narrow  path. 

In  making  an  osteoplastic  flap  for  approaching  the  brain  the  location  of 
the  flap  is  first  outlined  by  scratches  with  the  knife.  It  is  so  situated  that  the 
supposed  center  of  the  lesion  will  about  correspond  to  the  center  of  the  osteo- 
plastic flap,  and  it  is  planned  with  due  regard  to  the  nutrition  of  the  flap.  The 
base  of  the  flap  should  include  some  branches  of  the  temporal  or  occipital  ar- 
teries and  its  apex  should  point  toward  the  vertex  of  the  skull.  A  tourniciuet 
on  the  scalp  may  be  used  though  this  is  usually  unnecessary.  Bleeding  is 
best  controlled  by  a  firm  pressure  along  the  line  of  incision  with  the  fingers  of 
an  assistant,  making  the  incision  down  to  the  skull  for  about  two  inches  and 
then  controlling  the  bleeding  by  catching  the  galea  with  long  hemostatic  forceps 
and  turning  the  forceps  back,  as  has  already  been  described. 

The  first  section  of  the  incision  is  made  on  each  side  of  the  base  of  the 
flap.  A  periosteal  elevator  is  then  run  under  the  base  of  the  flap  as  close  to 
the  skull  as  possible  from  the  lower  end  of  one  of  these  incisions  to  the  other 
and  the  tissues  are  elevated.  A  light  strip  of  metal  is  thrust  under  the  flap  and 
another  placed  external  to  the  base  of  the  flap  and  the  ends  are  compressed  by 
a  rubber  band,  or  long  soft-blade  forceps,  such  as  are  used  in  stomach 
or  intestinal  suturing,  may  clamp  the  base  of  the  flap.  In  this  way  hemorrhage 
from  the  flap  itself  is  controlled  during  the  operation  and  at  the  same  time 
but  little  of  the  attachment  of  the  scalp  to  the  bone  is  affected.  The  incision 
following  the  scratched  line  already  made  is  completed  in  sections  with  but 
little  loss  of  blood.  The  scalp  should  not  be  detached  from  the  bony  por- 
tion of  the  proposed  osteoplastic  flap  and  the  pericranium  should  be  stripped 
up  away  from  the  flap.  The  skull  is  perforated  by  a  burr  at  any  point  along 
the  line  of  incision,  though  it  should  be  as  far  as  possible  from  the  site  of  the 
meningeal  vessels.  The  rest  of  the  procedure  may  be  carried  out  in  several  dif- 
ferent ways.  A  series  of  holes  can  be  made  with  the  burr  along  the  line  of 
incision  for  the  osteoplastic  flap  and  these  holes  are  connected  by  a  DeVilbiss 
forceps,  or  by  a  wire  saw,  which  is  carried  under  the  skull  from  one  per- 
foration to  another.  The  dura  is  protected  by  a  grooved  director  beneath  the 
saw  while  the  skull  is  being  divided.  A  very  satisfactory  method  is  to  make 
only  one  perforation  and  cut  the  rest  of  the  skull  with  a  DeVilbiss  forceps. 
When  the  skull  is  thick  this  may  be  a  laborious  process.  If  there  is  reason  to 
expect  close  adhesions  between  the  dura  and  the  skull  many  perforations  with 
a  burr  are  made  and  the  dura  is  separated  as  far  as  possible  between  these 
perforations  before  the  rest  of  the  skull  is  divided.  By  far  the  quickest  and 
least  laborious  method  is  with  the  rotarj^  saw.     This  may  be  dangerous  unless 


264  OPERATIVE    SURGERY 

handled  with  considerable  care.  It  should  never  be  used  without  a  guard  and 
the  saw  with  the  guard  is  started  from  a  perforation  that  has  been  made  with 
a  burr.  Even  with  the  guard,  however,  the  dura  will  be  occasionally  injured. 
The  bony  part  of  the  flap  near  the  base  is  divided  beneath  the  scalp  as  far 
as  possible,  taking  care  not  to  injure  the  soft  tissues  at  the  base  of  the  flap 
in  order  that  the  nutrition  of  the  bone  may  be  maintained.  The  base  of  the 
bony  flap  is  fractured  by  inserting  a  periosteal  elevator  under  the  bone  at  the 
apex  of  the  bony  flap  and  prizing  up  the  bone.  After  elevating  it  for  a  short 
distance  other  elevators  are  inserted  farther  down  on  the  side  of  the  bone 
flap  and  with  a  quick  jerk  the  base  of  the  bone  flap  is  fractured.  The  scalp 
and  the  bone  of  the  flap  are  wrapped  together  with  gauze  wrung  out  of  salt 
solution,  taking  particular  pains  not  to  separate  the  soft  tissues  from  the  bone. 

If  bleeding  occurs  in  the  bone  it  is  checked  by  pressing  into  the  bone  some 
bone  wax.  This  consists  of  a  mixture  of  beeswax  seven  parts,  almond  oil  one 
part,  and  salicylic  acid  one  part  and  serves  mechanically  to  stop  the  bleed- 
ing by  filling  up  the  channels  in  the  bone  which  contain  the  blood  vessels. 

The  incision  in  the  dura  depends  upon  the  character  of  the  pathology 
present.  If  the  lesion  can  be  seen  through  the  dura  before  the  dura  is  opened 
the  incision  is  made  in  such  a  manner  as  to  expose  it  most  satisfactorily.  If  the 
tumor  or  cyst  is  located  beneath  the  cortex  of  the  brain  a  flap  of  dura  is  made 
with  the  base  corresponding  to  the  base  of  the  osteoplastic  flap.  The  incision 
in  the  dura  should  not  be  nearer  the  bone  than  half  an  inch.  After  the  opera- 
tion is  completed  the  dura  is  sutured  with  continuous  sutures  of  fine  silk 
or  fine  catgut. 

The  location  of  the  flap  is,  of  course,  dependent  upon  the  location  of  the 
lesion  and  this  in  turn  is  determined  with  regard  to  the  special  centers  in  the 
brain.  The  region  of  these  centers  is  determined  by  measurements  on  the  sur- 
face of  the  skull.  The  old  well-established  method  is  that  of  Chipault.  This  re- 
quires working  out  in  each  case  the  percentage  distances  between  the  nasion  and 
the  inion.  The  nasion  is  the  median  part  of  the  junction  of  the  nasal  and  frontal 
bones  and  the  inion  is  the  external  occipital  protuberance.  According  to  the 
method  of  Chipault  a  line  is  drawn  along  the  middle  of  the  scalp  from  the 
nasion  to  the  inion.  This  line,  considered  as  100,  is  divided  into  percentages. 
The  top  of  the  fissure  of  Rolando  is  55  per  cent  of  the  distance  from  the  nasion. 
The  three  primary  lines  of  Chipault  are  drawn,  one  from  the  retro-orbital  tuber- 
cle, or  the  malar  tubercle  as  it  is  sometimes  called,  to  the  Sylvian  point,  which 
is  70  per  cent  of  the  distance  from  the  nasion  to  the  inion ;  the  second  is  the  lamb- 
doidal  line  which  runs  from  the  malar  tubercle  to  a  point  at  80  per  cent  of  the 
distance  from  the  nasion  to  the  inion  in  the  midline ;  and  the  third  is  the  lateral 
sinus  line,  which  marks  the  lateral  sinus  and  runs  from  the  malar  tubercle 
to  a  point  that  is  95  per  cent  of  the  distance  from  the  nasion  to  the  inion.  These 
three  primary  lines  are  divided  into  tenths  of  their  length.  Two  secondary 
lines  are  drawn,  one  of  which,  called  the  precentral  line,  passes  from  the  junction 
of  the  second  and  third  tenths  of  the  Sylvian  line  to  the  precentral  point  at  45 
per  cent  of  the  distance  from  the  nasion  to  the  inion  in  the  midline;  and  the 


SCALP,    SKULL,    AND   BRAIN 


265 


Kolaiulic  line  Avliicli  passes  between  the  junetiou  of  the  third  and  fourth  tenths 
of  the  Sylvian  line  to  the  Rolandie  point  which  is  55  per  cent  of  the  distance  from 
the  nasion  to  the  inion.  The  precentral  line  begins  at  the  bifurcation  of  the 
Sylvian  fissure,  and  lies  in  its  upper  two-thirds  over  the  precentral  fissure. 
The  Rolandic  line  lies  entireh'  over  the  whole  of  the  Rolandic  fissure. 

The  method  of  Reid  is  founded  on  a  base  line  which  is  drawn  horizontally 
from  the  lowest  margin  of  the  bony  orbit  through  the  center  of  the  external 
auditory  meatus  and  then  backward.     A   perpendicular  line  is   drawn   from 


Fig.    300. — Method    of    Rinkenberger    for    cerebral    localization. 


just  in  front  of  the  external  auditory  meatus  at  a  right  angle  to  the  base  line 
and  ends  at  the  median  line  above.  A  posterior  perpendicular  line  begins  at 
the  base  line  at  a  point  above  the  posterior  margin  of  the  mastoid  process  and 
goes  vertically  upward  to  the  midline  of  the  scalp.  The  Rolandic  fissure  is  rep- 
resented by  a  line  beginning  at  the  upper  end  of  the  posterior  perpendicular 
line  where  it  joins  the  anteroposterior  midline  of  the  scalp  and  passes  diago- 
nally downward  and  forward  to  a  point  where  the  Sylvian  line  crosses  the  ante- 
rior perpendicular  line.  The  Sylvian  line  extends  from  one  and  one-quarter 
inches  behind  the  external  angular  process  to  a  point  about  three-fourths  of  an 
inch  below  the  most  prominent  point  on  the  parietal  eminence. 


266  OPERATIVE   SURGERY 

F.  W.  Eiukeuberger^  describes  a  simplified  metliod  of  cerebral  localization, 
which  is  based  on  bony  landmarks  and  needs  no  measurement  (Fig.  300 j.  it 
requires  four  lines,  run  from  five  landmarks:  (1)  a  transverse  line  from  the 
glabella  to  the  lambda,  or  nasion  to  inion,  (2)  a  perpendicular  line  from  the 
posterior  part  of  the  mastoid  to  the  sagittal  suture,  (3)  a  perpendicular  from 
the  tubercle  of  the  z3^goma  to  the  sagittal  suture,  and  (4)  an  oblique  line  con- 
necting the  junction  of  the  zygoma  and  the  glabella-lambda  lines  with  the  upper 
end  of  the  mastoid  sagittal  suture  line.  This  oblique  line  will  practically  cover  the 
fissure  of  Rolando.  The  »Sylvian  point  lies  almost  beneath  the  tip  of  the  greater 
wing  of  the  sphenoid  where  it  joins  the  frontal  and  parietal  bones.  A  perpen- 
dicular line  up  from  the  midcQe  of  the  zygoma  until  it  meets  the  glabella- 
lambda  line  will  cover  the  Sylvian  point  at  the  junction  with  the  latter  line. 
If  the  giabelladambda  line  is  follow^ed  from  this  junction  to  the  mastoid-sagittal 
suture  line  the  fissure  of  Sylvius  will  be  fairly  accurate!}'  outlined.  The  line 
from  the  tubercle  of  the  zygoma  to  the  sagittal  suture  is  almost  over  the  ante- 
rior branch  of  the  middle  meningeal  artery,  the  artery  lying  not  more  than  one- 
fourth  inch  away  at  any  point. 

The  location  of  the  lesion  of  the  brain  having  been  determined  and  the 
osteoplastic  flap  made,  the  method  of  extraction  of  the  tumor  depends  upon  its 
shape,  consistency  and  depth.  If  the  growth  is  from  the  inner  surface  of  the 
dura,  or  if  it  involves  the  dura,  it  will  be  necessary  to  remove  this  membrane. 
If  the  dura  is  not  affected  and  the  lesion  is  under  the  cortex  it  will  often 
cause  a  protuberance  which  will  indicate  its  location.  The  brain  is  usually 
under  considerable  tension.  If  the  growth  is  not  an  infiltrating  growth  but 
is  encapsulated,  a  small  incision  is  made  through  the  cortex  of  the  brain  to  the 
growth  and  usually  after  a  few  minutes  the  growth  is  gradually  extruded 
from  the  brain.  It  is  highh^  important  to  handle  the  cortex  of  the  brain  with 
the  greatest  care.  It  should  not  be  touched  with  dry  sponges  and  it  is  pref- 
erable not  to  touch  it  at  all.  If  manipulation  of  the  cortex  of  the  brain  is 
necessary  it  is  done  gently  with  gauze  wrung  out  of  salt  solution.  If  the 
tumor  is  not  delivered  in  this  manner,  suction  may  be  applied  by  taking  the 
barrel  of  a  glass  syringe,  removing  the  piston  and  connecting  the  nozzle  of 
the  syringe  through  a  tube  with  another  syringe,  preferably  a  larger  one.  The 
base  of  the  barrel  of  the  syringe  is  placed  over  the  region  of  the  tumor  and 
suction  is  made  by  the  syringe  that  is  connected  with  the  nozzle  of  the  glass 
cylinder  barrel  applied  to  the  brain. 

If  bleeding  occurs  in  the  surface  of  the  brain  the  vessels  are  ligated  if 
possible  with  very  fine  silk  in  a  fine  curved  needle.  If  this  cannot  be  done  a 
piece  of  muscle  from  the  adjacent  muscular  tissue  in  the  soft  part  of  the  flap  is 
cut  and  crushed  in  a  forceps  and  laid  upon  the  bleeding  spot.  It  is  highly  im- 
portant to  leave  no  bleeding  surface  on  the  brain  or  in  the  tissue  that  will 
come  in  contact  with  the  brain. 

If  the  dura  must  be  excised,  or  if  there  are  many  adhesions  between  the 
cortex  and  the  dura,  which  may  be  the  whole  cause  of  the  trouble,  a  flap  of 


lAnn.   Surg.,   Sept.,   1918,  pp.  351-352. 


SCALP,    SKULL,    AND    BRAIN 


267 


fat  should  be  traiisi)laiit("(l.  The  details  of  this  will  he  described  later.  If 
the  fat  is  more  bulky  than  the  dura  a  portion  of  the  bone  in  the  osteoplastic  flap 
is  removed  in  order  to  prevent  too  much  compression  upon  the  brain  by  the 
fat.  The  flap  is  replaced  and  the  wound  is  closed,  preferably  without  drain- 
age, as  drainag-e  to  the  brain  may  be  followed  by  infection  or  adhesions. 
The  bone  should  be  carefully  replaced.  If  it  seems  to  rest  too  heavily  on 
the  dura  a  small  piece  of  fascia  is  interposed  at  intervals  between  the  edges 
of  the  bone  flap  and  the  edges  of  the  skull.  The  scalp  wound  is  sutured  as  has 
already  been  described,  taking  care  to  close  the  galea  accurately  and  to  maintain 
accurate  hemostasis  by  sutures.  The  galea  can  be  united  by  a  continuous 
suture  of  catgut  and  the  skin  by  silk,  horsehair,  silkworm-gut  or  fine  tanned 
catgut.  Too  much  pressure  should  not  be  made  over  the  region  of  the  flap, 
as  it  may  be  transmitted  to  the  brain. 


Fig.   301. — "Cross   bow"   incision   of   Gushing   for   exposure   of  the   cerebellum. 

The  method  just  outlined  can  be  used  with  a  few  variations  to  uncover  al- 
most any  region  of  the  cerebrum,  though  the  cerebellum  requires  a  different 
type  of  incision.  Here  the  "cross-bow"  incision  of  Gushing  gives  good  ex- 
posure (Fig.  301).  After  placing  the  patient  with  his  face  down,  a  curved  in- 
cision is  made  a  little  above  the  superior  curved  lines  of  the  occipital  bone.  A 
longitudinal  incision  goes  downward  from  the  middle  of  this  curved  incision 
onto  the  neck.  The  two  triangular  flaps  of  skin  which  are  formed  by  the 
junction  of  this  median  incision  with  the  curved  incision,  are  dissected  down- 
ward and  outward  until  the  insertion  of  the  flat  superficial  cervical  muscles 
is  seen.  Then  these  muscles  are  divided  transversely  about  three-fourths  of 
an  inch  below  their  insertion  and  a  median  vertical  incision  is  made  between 
the  muscles  down  to  the  spinous  process  of  the  upper  cervical  vertebra.  The 
ligamentum  nuehfe  is  split  in  the  midline  and  the  soft  parts  are  retracted.  The 
periosteum  is  elevated  from  the  occiput  and  in  this  manner  the  attachment  of 
the  deep  muscles  of  the  neck  is  separated.     The  skull  is  opened  through  the 


268  OPERATIVE    SURGERY 

prominence  of  the  occipital  bone  on  each  side  of  the  midline  with  a  burr  and 
the  opening  is  enlarged  with  rongeur  forceps.  The  ridge  of  bone  left  in  the 
midline  is  attacked  last  of  all  and  must  be  removed  with  care  because  of  the 
emissary  veins.  When  sufficient  bone  has  been  removed  the  middle  occipital 
sinus  is  ligated  and  the  dura  is  incised.  The  wound  is  closed  without  drainage 
unless  oozing  is  so  extensive  as  to  make  it  wise  to  insert  a  small  piece  of  rubber 
tissue  or  rubber  dam. 

OPERATIONS  FOR  EPILEPSY 

Operation  for  idiopathic  epilepsy  is  but  seldom  if  ever  justified.  When  a 
cause  is  found  for  cerebral  irritation  it  should  be  removed,  but  there  should  be 
at  least  a  reasonable  connection  between  the  lesion  and  the  epilepsy.  It  has 
been  well  known  that  any  sudden  shock  or  mental  strain  frequently  results  in 
the  cessation  of  epileptic  fits  and  this  too  frequently  has  been  construed  as 
therapeutically  following  the  operation. 

Undoubtedly  care  in  treating  fractures  of  the  skull  which  will  prevent 
unnecessary  scar  tissue  in  the  injured  brain,  the  dura  or  the  scalp,  tends  to 
prevent  epilepsy,  but  after  epilepsy  has  been  well  established,  even  when  there 
is  a  definite  lesion  of  the  brain,  the  removal  of  this  lesion  is  by  no  means  always 
curative.  Such  cases,  however,  are  proper  subjects  for  operation,  but  the 
ultimate  results  are  not  always  gratifying. 

Keen  has  laid  much  emphasis  on  the  excision  of  the  scar  in  the  scalp,  and 
if  he  finds  no  injury  to  the  bone  he  removes  the  scar  in  the  scalp,  unites  the 
wound  carefully,  and  awaits  the  result  of  this  operation.  There  are,  however, 
many  instances  of  injury  to  the  brain  that  result  in  focal  or  Jacksonian  epi- 
lepsy, in  which  the  lesion  can  be  definitely  localized.  It  seems  reasonable  to 
suppose  that  if  this  is  true  similar  lesions  in  silent  areas  in  the  brain  may 
cause  a  general  epilepsy  without  producing  focal  symptoms.  Of  course,  in 
every  such  case  a  competent  neurologist  should  be  consulted  and  treatment 
directed  to  allay  excitement  and  irritation  to  the  brain  should  be  instituted. 

The  object  of  operating  upon  the  brain  for  epilepsy  is  to  remove  some 
lesion  causing  irritation.  This  in  some  instances  may  be  a  tumor  or  a  cyst 
resulting  from  a  previous  injury  that  produced  a  localized  clot  or  destruc- 
tion of  tissue.  If  a  tumor  or  a  cyst  exists  it  is  dealt  with  along  the  prin- 
ciples that  have  already  been  indicated  for  a  brain  operation.  If  the 
trouble  is  due  to  adhesions  between  the  cortex  of  the  brain  and  the  dura,  the 
problem  becomes  more  complicated.  If  the  cortex  of  the  brain  contains  a  scar, 
excision  of  this  scar  will  probably  give  only  temporary  benefit.  If  the  lesion 
is  strictly  focal  and  the  whole  center  governing  the  convulsive  portion  of  the 
body  is  removed,  then,  of  course,  permanent  paralysis  results  and  there  is  at 
least  a  possibility  of  the  contraction  of  the  resulting  wound  involving  neigh- 
boring centers.  This  method  of  operation  should  be  resorted  to  very  guardedly, 
if  at  all,  and  only  when  the  region  of  the  brain  involved  is  very  small  and  the 
disease  sharply  outlined. 


SCA1>1',    SKULL,    AND    BRAIN 


269 


Acllicsioiis  hctwccii  the  t'oi-tcx  of  the  hriiiii  lo  liic  tlura,  oi',  if  llie  dura  is 
desti'oy(Ml,  to  tlu>  structures  ovorlyiu<>'  the  brain,  are  responsible  for  many 
cases  of  foeal  epilepsy.  Mereh'  separating  these  adhesions  and  suturing  the 
tissues  does  only  temporary  good.  The}'  will  almost  certainly  re-form  and  the 
trauma  of  the  operation  may  even  add  to  their  extent.  The  problem  is  some- 
what ditt'erent  from  that  in  the  abdomen  when  the  separation  of  adhesions  is 
sometimes  accompanied  by  removal  of  the  cause  of  the  adhesions,  or  at  least  by 
the  opportunit}'  to  cover  the  two  opposing  raw  surfaces  with  peritoneum.  The 
mobility  of  the  abdominal  viscera  also  aids  in  the  prevention  of  adhesions.  The 
complicated  tissues  of  the  brain  have  poor  regenerative  powers  and  the  cortical 
cells  and  their  dendrites  never  regenerate.  All  of  these  things  greatly  favor 
not  only  the  formation  of  scar  tissue  after  any  injury  to  the  l)rain  but  the 
adhesions  of  the  cortex  of  the  brain  to  its  overlying  tissue. 


Fig.  302. — Lines  of  incision  for  operation  for  exposure  of  the  dura  and  brain  after  an  old  depressed  fracture. 

The  adhesions  may  be  from  the  arachnoid  or  the  piamater  to  the  dura. 
Naturally  the  physiologic  expansion  and  contraction  of  the  brain  makes  such 
adhesions  a  source  of  considerable  irritation  and  in  individuals  who  are  predis- 
posed to  convulsive  seizures  epilepsy  may  occur. 

The  methods  of  preventing  adhesions  of  the  cortex  of  the  brain  to  the 
dura  have  been  numerous.  Most  of  them  unfortunately  have  not  been  consid- 
ered from  a  biologic  viewpoint,  but  solely  mechanically.  It  has  apparently 
been  conceived  in  some  instances  that  if  a  piece  of  rubber  tissue,  or  a  strip  of 
celluloid,  or  a  gold  or  silver  leaf  would  prevent  two  objects  from  touching 
each  other,  the  same  method  would  prevent  adhesions  of  the  brain  to  its  over- 
lying structures.  As  a  rule,  the  interposition  of  foreign  material  between  the 
cortex  of  the  brain  and  the  dura  and  its  overlying  tissues  means  not  a  preven- 
tion but  an  increase  of  adhesions.  It  maj^  for  a  time  be  physically  impossible 
for  adhesions  to  penetrate  the  center  of  this  foreign  material  and  there  are 
some  foreign  substances  that  are  less  irritating  than  others.     The  logical  out- 


270 


OPERATIVE    SURGERY 


come  of  these  procedures,  however,  can  easily  be  anticipated  by  anyone  who 
has  followed  a  small  amount  of  experimental  work  in  burying  foreign  sub- 
stances in  any  portion  of  the  body.  If  the  foreign  substance  is  absorbable  and 
no  infection  occurs,  it  may  be  absorbed  if  not  too  large,  and  its  place  is  usually 
taken  by  organized  connective  tissue.  If  it  is  nonabsorbable,  as  gold  or  silver 
leaf,  rubber  tissue  or  celluloid,  nature  tends  to  encapsulate  the  material  and 
adhesions  are  formed  around  the  edge  of  the  foreign  substance.  The  contrac- 
tion of  the  adhesions  not  infrequently  results  in  the  crumpling  up  of  the 
foreign  substance  until  it  may  be  broken  into  smaller  pieces  or  rolled  up  in  a 


Fig.    303. — The  adherent   dura   and   tissues   have   been    removed   and   the   brain   is   exposed.      A  flap    of   scalp 
and  a  flap  of  pericranium  witli  some  bone  attached  are  mobilized. 

mass.  Anyone  who  has  seen  a  sponge  or  a  piece  of  gauze  accidently  left  in  the 
abdominal  cavity  and  removed  weeks  or  months  later  can  draw  a  very  good 
mental  picture  of  what  happens  in  a  smaller  way  when  foreign  substances  are 
left  on  the  cortex  of  the  brain. 

The  transplantation  of  fascia  or  muscle  over  the  denuded  cortex  is  followed 
by  adhesions.  The  only  substance  which  seems  to  give  satisfactory  results  that 
justify  transplantation  of  tissue  is  fat,  which  has  been  employed  successfully 
by  Lexer,  Dean  Lewis,  and  others.  This  may  be  obtained  either  from  the 
abdomen  or  from  the  thigh. 

A  satisfactory  flap  can  be  removed  from  the  fascia  of  the  thigh,  taking 


SCALP,    SKULL,    AND    BRAIN 


271 


a  coating  of  fat  on  the  fascia  lata  and  transplanting  the  fat  and  fascia  to  the 
brain,  placing  the  fat  next  to  tlie  cortex.  The  fascia  is  united  to  the  edges  of 
the  dura  by  a  few  catgut  sutures.  It  is  best  to  split  the  dura  in  several  di- 
rections and  to  insinuate  the  edges  of  the  fat  under  the  edges  of  the  dura. 
It  is  highly  important  in  such  cases  to  remove  sufficient  bone  from  the  skull  so 
that  the  replacement  of  an  osteoplastic  flap  will  not  produce  too  much  pressure 
upon  the  fatty  transplant,  which  is  normally  much  thicker  than  the  dura  (Figs. 
302,  303,  304  and  305). 

In  performing  such  operations  the  lesion  is  usually  indicated  by  the  scar 
on  the  scalp  and  it  is  best  so  to  shape  the  flaps  of  scalp  as  to  enable  the  operator 


Fig.   304. — A  fatty  fascia  flap   from   the  thigh   has   Ijeen   sutured   over  the   defect   in   the   dura. 

to  excise  the  scar  in  the  scalp  and  to  enter  the  skull  on  the  margin  of  the 
supposed  area  of  adhesion  and  not  in  its  center.  The  skull  immediately  over 
these  adhesions,  if  the  area  is  not  too  extensive,  should  be  removed  entirely,  so 
when  the  scalp  is  replaced  there  is  no  bone  over  the  fatty  flap  to  produce 
compression. 

In  three  cases  of  epilepsy  following  trauma  to  the  skull  and  brain  I  have 
used  this  method  of  transplanting  a  fatty  fascia  flap.  Two  of  these  patients 
have  so  far  made  a  very  satisfactory  recovery.  The  third  has  been  considerably 
benefited,  but  is  not  cured.  It  may  be  that  the  operation  in  this  instance  merely 
produced  a  temporary  alleviation.    In  one  of  the  two  cases  in  which  the  result 


172 


OPERATIVE    SURGERY 


was  considered  satisfactory  the  patient  liad  been  previously  operated  upon  for 
general  epilepsy  elsewhere  and  a  large  osteoplastic  flap  had  been  turned  down 
over  the  motor  area.  For  several  years  he  appeared  to  be  relieved  of  his 
epilepsy,  but  later  began  having  convulsive  seizures  of  his  left  forearm  and 
hand.  These  were  not  accompanied  by  unconsciousness.  They  would  recur  at 
intervals  of  fifteen  minutes  to  half  an  hour.  Operation  showed  marked  adhe- 
sions of  the  piamater  and  arachnoid  and  of  the  cortex  of  the  brain  to  the  dura 


Fig.    305. — The    flap   of   pericranium    is   transferred   over    the   fatty   fascia   graft. 

over  the  arm  and  hand  center.  Elsewhere  the  cortex  of  the  brain  appeared  to 
be  normal  and  nonadherent.  The  adhesions  were  divided  wath  a  sharp  knife 
and  a  fatty  fascia  transplant  was  made  with  the  fat  next  to  the  surface  of  the 
brain.  The  arm  and  hand  were  paralyzed  for  several  days  and  then  weak  mo- 
tion began  and  finally  the  motion  appeared  about  normal.  When  last  heard 
from  about  two  years  after  the  operation,  the  patient  had  had  no  further  con- 
vulsive seizures  in  his  arm  and  hand  and  the  motion  had  returned  satisfactorily. 


OPERATIONS  FOR  HYDROCEPHALUS 

Many  years  ago,  Hilton,  in  "Eest  and  Pain,"  stated  that  hydrocephalus 
was  due  to  obstruction  of  the  outlet  of  the  cerebrospinal  fluid  from  the  brain. 
Recent  research  seems  to  emphasize  Hilton's  views. 


SCALP,    SKULL,    AND    BRAIN  273 

The  cerebrospinal  tiiiid  coiiu's  from  tlie  choroid  plexus.  About  three-fourths 
of  the  choroid  i)lexus  lies  in  the  two  lateral  ventricles,  the  third  and  fourth  ven- 
tricles containing  the  remaining  fourth.  The  cerebrospinal  fluid  makes  its  way 
through  the  aqueduct  of  Sylvius  to  the  fourth  ventricle,  through  the  foramina 
of  Luschka  and  Magendie  to  the  subarachnoid  space.  Absorption  of  the  cerebro- 
spinal fluid  is  practically  entirely  from  the  subarachnoid  space.  The  existence  of 
fanciful  stomata  and  the  absorptive  powers  of  the  pacchionian  bodies  have  been 
disproved.  Normal  absorption  of  cerebrospinal  fluid  takes  place  slowly  by  osmosis 
through  the  membrane  of  the  subarachnoid  space.  The  subdural  space  has 
but  little  absorptive  capacity.  The  communication  bef-ween  the  fluids  of  the 
ventricles  and  the  subarachnoid  spaces  normally  exists  only  through  the  fourth 
ventricle  and  the  foramina  of  Luschka  and  Magendie.  In  the  absence  of  these 
normal  openings  this  communication  can  apparently  be  satisfactorih'  main- 
tained only  through  openings  made  in  this  region. 

Operations  for  hydrocephalus  that  are  designed  to  cause  absorption  of  the 
cerebrospinal  fluid  by  transferring  it  to  other  portions  of  the  body  cannot 
in  the  nature  of  things  be  successful.  The  only  benefit  is  the  temporary  reduc- 
tion of  pressure  by  removing  the  cerebrospinal  fluid  during  the  operation  and 
the  decompressive  effect  of  removal  of  a  portion  of  the  skull.  It  is  Avell  known 
that  forced  absorption  of  fluid  in  tissues  of  the  bodj^  as  illustrated  by  a  continuous 
hypodermoclysis  of  salt  solution  is  temporary.  The  blockage  of  lymphatics 
in  the  region  of  the  hypodermoclysis  produces  such  a  condition  in  the  tissues 
that  but  little  fluid  is  absorbed  after  a  few^  days  and  that  only  under  great 
pressure.  If  sufficient  pressure  existed  within  the  ventricles  of  the  brain  to 
force  the  absorption  of  the  cerebrospinal  fluid  after  it  has  been  conducted 
into  the  tissues  of  the  neck,  scalp  or  chest,  the  pressure  itself  would  cause  de- 
struction of  the  brain.  Operations  for  creating  a  channel  between  the  ventri- 
cles of  the  brain  and  the  sinuses  of  the  dura  sooner  or  later  result  in  closure  of  ■ 
the  channel. 

Hydrocephalus  should  be  differentiated  from  acute  inflammation  of  the 
brain  in  which  there  is  an  exudate  from  va[rious  tissues.  This  exudate  ceases 
when  the  irritation  of  inflammation  or  trauma  has  subsided.  For  practical  pur- 
poses it  may  be  said  that  there  is  only  one  type  of  hydrocephalus,  the  obstructive 
form.  The  obstruction  may  exist  along  the  aqueduct  of  Sylvius  or  in  the  roof 
of  the  fourth  ventricle  or  in  the  subarachnoid  space,  which  permits  only  a 
limited  amount  of  absorption  of  cerebrospinal  fluid,  but  is  not  a  complete 
blockage  as  would  be  in  obstruction  of  the  aqueduct  of  Sjdvius.  In  the  form 
of  obstructive  hydrocephalus  in  which  the  obstruction  is  located  at  some  dis- 
tance from  the  fourth  ventricle,  the  fluid  communicates  with  this  limited  area 
of  subarachnoid  space  and  with  the  spinal  cord. 

It  can  readily  be  seen,  then,  that  an  operation  which  merely  conducts  the 
cerebrospinal  fluid  into  tissues  of  the  scalp  or  neck  cannot  succeed  for  reasons 
that  have  been  mentioned.  Operations  such  as  puncture  of  the  corpus  callosum 
merely  transfer  the  cerebrospinal  fluid  from  the  ventricles  of  the  brain  to  the 
subdural  space  where  almost  no  absorption  takes  place,  the  cerebrospinal  fluid 


274  OPERATIVE  SURGERY 

being  absorbed  from  the  subarachnoid  space.  The  problem,  then,  particularly  in 
the  communicating  type  of  hydrocephalus,  in  which  a  small  portion  of  the 
subarachnoid  space  near  the  fourth  ventricle  is  still  left  but  is  shut  off  by  ad- 
hesions from  the  larger  subarachnoid  space,  consists  in  so  reducing  the  forma- 
tion of  cerebrospinal  fluid  that  the  amount  that  is  secreted  can  be  absorbed. 

Walter  E.  Dandy,-  of  Baltimore,  has  devised  an  operation  for  removal  of 
that  portion  of  the  choroid  plexus  vi^hich  lies  in  the  lateral  ventricles.  It  is  im- 
practicable to  remove  the  choroid  plexus  from  the  third  and  fourth  ventricles 
and,  as  three-fourths  of  the  amount  is  in  the  lateral  ventricles,  the  absorption 
of  the  cerebrospinal  fluid  formed  from  the  twenty-five  per  cent  of  choroid 
plexus  left  in  the  third  and  fourth  ventricles  can  probably  be  done  by  the 
limited  amount  of  subarachnoid  space  remaining.  Before  attempting  the 
operation,  however,  it  should  be  determined  that  the  hydrocephalus  is  of 
the  communicating  type,  in  which  the  obstruction  is  in  the  subarachnoid 
space.  This  is  done  by  injection  of  one  cubic  centimeter  of  neutral  phenol- 
sulphonephthalein  into  either  of  the  lateral  ventricles  of  the  brain.  This  solution 
is  especially  prepared  and  the  drug  that  is  ordinarily  used  to  test  kidney  func- 
tion is  not  satisfactory.  If  the  hydrocephalus  is  of  the  communicating  type  a 
lumbar  puncture  done  half  an  hour  later  will  demonstrate  the  dye  in  the  spinal 
fluid,  but  if  the  obstruction  exists  in  the  ventricular  system  the  spinal  fluid 
will  remain  colorless. 

If  the  operation  of  Dandy  is  indicated,  it  is  done  as  follows:  A  small 
circular  bone  flap  is  made  over  the  parietal  eminence  with  the  base  toward 
the  midline  and  so  located  that  it  is  well  posterior  to  the  Rolandic  area.  The 
flap  of  bone  and  then  of  dura  is  turned  up,  and  the  vessels  in  the  cortex  of  the 
brain  are  tied  with  fine  silk  and  the  cortex  of  the  brain  is  incised  down  to  the 
ventricle.  Into  this  incision  is  inserted  a  nasal  dilating  speculum,  or  if  the 
ventricle  is  very  large  a  spatula  may  be  used.  After  removing  all  of  the  cere- 
brospinal fiuid  the  choroid  plexus  is  recognized  as  a  brownish-red  flocculent 
substance  and  is  picked  up  with  forceps  at  the  foramen  of  Monro.  The  vessels 
are  ligated  with  a  silver  clip,  clamping  a  small  piece  of  silver  wire  on  the 
vessel  with  especially  constructed  forceps.  A  small  pledget  of  moist  cot- 
ton is  inserted  gently  into  the  foramen  of  Monro  to  prevent  blood  from 
gaining  access  to  the  third  ventricle.  The  choroid  plexus  is  cut  and  gently 
stripped  back  to  the  floor  of  the  body  of  the  ventricle.  When  the  glomus 
is  reached,  the  choroid  plexus  is  then  picked  up  again  at  the  tip  of  the  descend- 
ing horn  of  the  ventricle  and  similarly  stripped  backward  from  this  point  to  the 
glomus  when  the  attachment  to  the  glomus  is  liberated  and  the  entire  choroid 
plexus  removed.  Bleeding  is  slight  but  should  be  completely  controlled  by 
cotton  pledgets  soaked  in  salt  solution.  Great  care  must  be  taken  to  leave  no 
bleeding  points.  The  cavities  that  are  left  would  cause  collapse  of  the  brain 
and  are  filled  with  salt  solution.     The  opening  in  the  cortex  of  the  brain  is 


2Ann.  Surg.,  Dec,  1918,  pp.  569-580. 


SCALP,    SKULL,    AND    BRAIN  275 

closed  Willi  iiitornipted  sutures  oC  fine  silk  in  the  piaraeter  and  araehnoid.  The 
dura  aud  sealp  are  closed  with  sillv,  taking  care  to  have  no  leakage.  A  similar 
procedure  is  carried  out  on  the  other  side  at  a  different  time. 

Four  cases  operated  up)on  in  this  manner  by  Dandy  have  all  survived  the 
immediate  effects  of  the  operation,  though  three  died  from  two  to  four  weeks 
after  the  operation.  One  was  living  and  showed  no  evidence  of  return  of 
the  disease  ten  months  after  operation. 

The  operation  is,  of  course,  a  severe  one  and  should  not  be  lightly  under- 
taken but  it  is  founded  on  scientific  knowledge  of  the  etiology  and  pathology 
of  hydrocephalus. 

Puncture  of  the  corpus  callosum  may  relieve  temporarily  the  tension  of 
the  fluid  in  the  ventricles  of  the  brain  and  in  instances  in  which  this  fluid  is 
due  to  inflammation  or  trauma  may  be  advisable,  as  has  already  been  explained. 
It  can  hardly  be  curative  in  true  hydrocephalus,  because  the  fluid  is 
drained  into  the  subdural  space  instead  of  the  subarachnoid  and  there  is 
but  little  absorption  in  the  subdural  space.  This  operation  is  done  pref- 
erably in  the  anterior  third,  or  at  least  in  the  anterior  two-thirds,  of  the  corpus 
callosum,  because  the  corpus  is  thinner  at  this  portion.  A  small  U-shaped  flap 
of  scalp  is  made  with  its  base  at  the  midline,  or  a  straight  incision  can  be  used. 
The  exposure  of  the  skull  is  so  located  that  the  bone  can  be  reached  about  half 
an  inch  from  the  midline  and  the  same  distance  posterior  to  the  coronary  su- 
ture. The  dura  is  opened,  and  a  blunt  malleable  needle  is  passed  downward 
and  inward  until  it  reaches  the  falx  cerebri,  which  serves  as  a  guide  to  the  corpus 
callosum.  The  needle  is  then  gently  pressed  through  the  corpus  and  fluid  should 
immediately  flow.  The  opening  in  the  corpus  callosum  is  enlarged  by  moving 
the  needle  forward  and  backward  for  about  half  an  inch.  The  wound  is  closed 
in  the  usual  manner  without  drainage.  A  probe  may  sometimes  be  used  in- 
stead of  a  needle.    Either  instrument  should  have  a  scale  marked  upon  it. 

The  lateral  ventricle  can  also  be  punctured  by  the  method  advocated  by  Keen. 
Here  a  point  is  indicated  about  one  inch  behind  and  one  inch  above  the  external 
auditory  meatus  and  in  the  posterior  part  of  the  first  temporal  convolution. 
After  removing  a  small  piece  of  skull  and  opening  the  dura  the  needle  is  di- 
rected inward  and  toward  the  top  of  the  ear  on  the  opposite  side.  The  ventricle 
is  about  two  inches  from  the  surface  of  the  brain. 

OPERATIONS  ON  THE  HYPOPHYSIS 

Operations  for  removal  of  tumors  of  the  hypophysis  have  been  performed 
through  the  nasal  route  or  through  the  region  of  the  frontal  bone.  This  latter 
has  been  developed  into  a  standard  operation  and  appears  to  be  the  method  of 
choice. 

The  method  that  gives  most  satisfactory  approach  seems  to  be  an  attack 
by  a  frontal  osteoplastic  flap.  This  operation  has  been  devised  by  Mc Arthur. 
A  flap  is  made  with  its  pedicle  in  the  temporal  region.  An  incision  outlining 
this  flap  goes  from  the  midpoint  between  the  eyebrows  up  the  middle  of  the 


276  OPERATIVE    SURGERY 

forehead  to  the  region  of  the  normal  hair-line.  The  incision  is  carried  outward 
and  a  third  incision  is  begun  at  the  lower  end  of  the  frontal  incision  and  goes 
outward  along  the  upper  part  of  the  eyebrow  to  the  outer  margin  of  the  orbit. 
Care  is  taken  to  keep  the  periosteum  intact  and  as  closely  connected  with  the 
bone  in  the  region  of  the  flap  as  possible.  The  skull  is  perforated  at  the  upper 
outer  angle  of  the  flap  with  a  burr  or  a  small  trephine.  The  ujiper  and  middle 
portion  of  the  bone  flap  is  separated  with  a  DeVilbiss  forceps.  The  lower 
part  of  the  vertical  cut  in  the  bone  is  deflected  somewhat  toward  the  base 
of  the  flap  so  as  to  avoid  the  frontal  sinus.  The  lower  horizontal  cut  in  the 
bone  ends  just  above  the  outer  angle  of  the  orbit,  invading  slightly  the  temporal 
fossa.  The  external  angular  process  of  the  frontal  bone  is  divided  with  a  sharp 
chisel  or  a  saw.  The  internal  bony  portion  of  the  supraorbital  arch  is  also 
divided,  going  through  well  into  the  orbital  plate  of  the  frontal  bone.  This 
ridge  of  the  frontal  bone  is  removed  and  kept  in  salt  solution  until  the  operator 
is  ready  to  replace  the  flap.  The  bony  roof  of  the  orbit  is  then  removed  with 
rongeur  forceps  until  the  optic  nerve  is  exposed.  The  dura  is  separated  from 
the  bone  in  its  neighborhood.  The  anterior  clinoid  process  is  recognized.  A 
transverse  incision  about  an  inch  long  is  made  in  the  dura  between  the  clinoid 
processes  about  three-eighths  of  an  inch  above  the  level  of  the  floor  of  the  ante- 
rior fossa.  Through  this  opening  the  optic  nerve,  the  chiasm,  and  the  pituitary 
tumor  come  into  view.  After  removing  the  tumor  or  evacuating  the  fluid  the 
frontal  lobe  is  permitted  to  fall  into  place.  The  ridge  of  bone  removed  from 
the  upper  margin  of  the  orbit  is  replaced  and  held  in  position  by  sutures.  The 
osteoplastic  flap  is  turned  in  position  and  fastened  in  the  usual  manner. 

This  operation  has  been  modified  and  greatly  improved  by  Adson  and  by 
Heuer.  The  osteoplastic  flap  is  made  by  Adson  with  the  base  in  the  temporal 
region  and  the  incisions  placed  much  farther  back,  so  the  flap  is  largely  in  the  hair 
region.  The  frontal  sinus  is  thus  avoided.  The  dura  is  incised  freely  as  a  flap 
and  the  brain,  protected  with  strips  of  rubber  tissue  and  moist  cotton,  is  gently 
elevated  with  a  broad  spatula  until  the  optic  chiasm  and  the  tumor  are  seen.  The 
tumor  is  removed  gently  from  within  its  capsule,  if  possible,  leaving  no  bleeding 
points. 

CONGENITAL  HERNIAS  OF  THE  BRAIN  OR  ITS  MEMBRANES 

There  are  occasionally  found  protrusions  or  hernias  of  the  membranes  of 
the  brain  or  of  the  brain  itself.  They  come  through  a  congenital  opening  in 
the  bones.  If  much  of  the  brain  is  involved  and  the  opening  is  large  but  little 
can  be  done  except  general  compression,  w^iich  must  not  be  too  great,  with  the 
hope  that  if  this  defect  occurs  in  young  children  or  infants  the  development 
of  the  growing  child  may  remedy  the  defect.  The  prognosis  is  usually  bad. 
When  the  sac  consists  solely  of  the  membranes  of  the  brain  and  contains  fluid, 
and  when  there  is  no  hydrocephalus  or  spina  bifida,  an  attempt  at  radical  cure 
may  be  made.  If  the  opening  in  the  bone  is  small  there  is  considerable  prospect 
of  cure,  though  the  operation  must  be  carried  out  with  care  as  to  the  details 


SCAT.P,    SKULL,    AND    BRAIN 


277 


and  must  be  midei'takoii  before  tlie  sac  lias  ruptured,  and,  if  possible,  before 
the  skin  on  the  sac  has  become  ulcerated.    It  is  best  to  use  local  anesthesia. 

Flaps  with  broad  bases  are  dissected  from  the  base  of  the  meningeal  sac. 
They  should  include  healthy  skin.  The  incision  is  made  with  a  sharp  knife 
and  great  care  is  taken  to  avoid  opening  the  sac.  Every  bleeding  point  is  caught 
with  forceps.     After  reaching  the  bone  the  neck  of  the  sac  is  cleared  around 


Fig.  306. — Photograph  of  baby  with  meningocele  in   the  lower  pari  of  the  occipital  bone. 


Fig.   307. — Lines  of  incision  for   excision  of  the  meningocele   shown   in  preceding   figure. 


the  bony  margin.  If  the  neck  of  the  sac  is  thin  it  should  be  very  gently  sep- 
arated from  the  bony  margin.  If  it  is  thick  careful  dissection  with  a  sharp 
knife  removes  the  excessive  tissue  and  leaves  the  sac  at  its  neck  consisting  al- 
most entirely  of  the  protruding  dura.  "When  the  sac  has  been  thoroughly  freed 
from  the  margins  of  the  opening  in  the  bone  and,  if  possible,  from  the  bone 
for  a  short  distance  under  the  margin,  a  ligature  of  tanned  catgut  is  tied  around 
the  sac  as  closely  as  possible  to  the  normal  surface  of  the  brain.  While  tying  this 
ligature  no  pressure  is  made  upon  the  sac  which  would  force  an  undue  amount 


278 


operatrt:  st-rgert 


of  cerebrospinal  fluid  back  onto  the  brain.  After  this  ligature  has  been  securely 
placed  the  sac  is  cut  away.  The  stump  of  the  sac  is  transfixed  with  catgut  in 
a  needle  slightly  distal  to  the  ligature  and  whipped  over  and  tied  in  order  still 
further  to  secure  the  stump  from  leaking.    A  flap  of  pericranium  is  turned  over 


Fig.   308. — A  cuft   of   scalp   is   turned   back,    the   opening   in   the   skull   thoroughly    exposed,    and   a   ligature 

is  placed  around  the  neck  of  the  sac. 


Fig.    309. — The    neck    of    the    sac    is    ligated. 


The    lines    show    the    incision    for    turning    over    a    flap    of 
pericranium. 


the  pedicle  and  sutured  in  position  to  the  pericranium  on  the  other  side  of  the 
opening  in  the  bone.  The  flap  of  scalp  that  has  previously  been  formed  should 
be  abundant  and  is  placed  in  position  by  suturing  the  galea  or  by  everting 
two  flaps  of  scalp  and  using  a  series  of  mattress  sutures  to  give  a  lateral  ap- 
proximation to  the  galea.    The  skin  is  approximated  with  a  continuous  epithelial 


SCALP,    SKUIiL,    AND    BRAIN 


279 


stitch  of  fine  sillc.  AVhetlier  one  or  two  flaps  of  scalp  are  formed  depends  upon 
the  condition  of  the  scalp  at  the  base  of  the  meningocele  (Figs.  306,  307,  308, 
309  and  310). 

In  a  bah}'  three  months  old  with  the  meningocele  in  the  lower  part  of  the 
occipital  bone,  I  performed  the  operation  just  outlined  and  the  baby  made  a 


Fig.    olO. — The    flap    of    pericranium    is    sutured    into    position. 

satisfactory  recovery.  When  last  heard  from,  about  twenty  months  after  the 
operation,  the  baby  was  improving  and  seemed  to  be  developing  mentally  in 
a  satisfactory  manner. 

DECOMPRESSION  OPERATIONS 

Operations  for  decompression  of  the  brain  have  become  popular  since 
Harvey  Gushing  established  the  principle  of  performing  this  operation  in  the 
subtemporal  region  in  such  a  manner  that  the  fibers  of  the  temporal  muscle 


Fig.    311. — Line    of    incision    for    subtemporal    decompression.      Where    the    decompression    is    to    be    more 
extensive,   the  incision  may  incline  farther  backward. 


280 


OPERATIVE   SURGERY 


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Fig.   312. — The  fibers   of  the  temporal  muscle  are  separated  and  the  pericranium  and   skull  are   exposed. 


Fig.   313. — The  skull   is  perforated  with  a  drill   or  burr. 


serve  as  a  restraining  influence  to  the  protrusion  and  so  prevent  the  enormous 
hernia  that  occurs  when  the  decompression  is  made  near  the  vault  of  the  skull, 
where  there  is  nothing  to  inhibit  the  protrusion  of  the  brain  except  the  skin 
and  fascia  of  the  scalp. 

According  to  Gushing 's  original  technic  a  curved  incision  is  made   about 


SCALP,    RKI'LL,    AND    BRAIN 


281 


one  ineli  liclnw  t1io  tcnipoi"il  ridiii'  in  the  ori<iiii  of  the  tcmi)oral  muscle.  This 
is  entirely  within  the  h;iir\-  ptJiiimi  of  tlie  scalp.  A  flap  of  skin  and  subcu- 
taneous tissue  alone  is  reflected  downwai-d,  takin^u'  care  to  avoid  injui'v  to  the 


Fii?.    314. — The  dura  is  incised  after  picking   it  up  with   the   point  of  a  needle. 


pig_    315. — The    dura    has   been   split    and    the    bulging    brain    is    e.xposed. 


temporal  fascia.  The  temporal  fascia  is  then  split  in  the  direction  of  its  fibers 
where  it  runs  downward  and  forward  and  the  edges  of  the  wound  in  the  fascia 
are  retracted  while  the  temporal  muscle  is  split  between  the  bundles  of  its  fibers. 


282 


OPERATIVE    SURGERY 


Great  care  is  taken  not  to  cut  across  the  muscle  fibers  of  the  temporal  muscle, 
and  also  to  preserve  the  origin  of  the  temporal  muscle.  The  pericranium  is  sepa- 
rated from  the  bone  all  around  the  region  of  the  wound  which  is  retracted  to 
afford  ample  space  (Fig.  312).  The  skull  is  perforated  with  a  burr,  the 
dura  separated  (Fig.  313),  and  as  much  of  the  skull  as  possible  is  removed 
from  beneath  the  elevated  soft  parts,  separating  the  dura  well  from  the  skull  be- 
fore removing  each  bite  of  bone.  Any  unusual  bleeding  of  the  bone  may  be 
controlled  with  bone  wax.  An  opening  is  made  which  is  carried  well  down 
to  the  region  of  the  zygoma.  An  area  of  bone  from  two  and  one-half  to  three 
inches  in  diameter  is  removed  (Fig.  314).  A  cross  incision  is  made  in  the  dura, 
which  is  split  in  radiating  directions  from  the  center  of  the  wound.  The  incis- 
ion in  the  dura  should  not  be  carried  quite  to  the  margin  of  the  bone  so  as  to 


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Fig.    316. — The  wound  is   closed  by  suturing  first  the   fibers   of   the  temporal  muscle,   then   the   galea,   and 
finally  the  skin.     Closing  the  galea  accurately  is  an  important  step  in  any  operation  on  the  scalp. 

protect  the  brain  from  injury  by  the  bone  when  it  protrudes  through  the  open- 
ing in  the  skull  (Fig.  315).  The  branches  of  the  meningeal  artery  may  be 
tied  in  this  operation.  The  muscle  is  brought  together  with  a  few  interrupted 
catgut  sutures  and  the  temporal  fascia  is  closed  Avith  continuous  sutures  of  fine 
tanned  catgut.  The  galea  is  sutured  separately  and  the  skin  is  closed  in  the 
usual  manner  for  scalp  operations  (Fig.  316). 

The  advantages  of  this  method  of  decompression  are  obvious,  as  it  gives 
access  to  a  region  of  the  brain  that  is  frequently  the  site  of  abscesses  or  tumors, 
it  involves  the  silent  area  of  the  brain,  and  the  support  of  the  temporal  muscle 
and  fascia  is  obtained,  which  prevents  undue  protrusion  of  the  brain,  while 
permitting  relief  from  excessive  intracranial  pressure. 

The  details  of  the  decompression  operation  have  been  modified  in  the 
method  of  incision.     Instead  of  using  a  curved  incision,   as   Gushing  recom- 


SCALP,    SKUIiL,    AND    BRAIN  283 

mends,  a  straight  incision  may  be  made  beginning  about  the  middle  of  the  zygoma 
and  going  npAvard  and  backward  for  about  three  and  one-half  inches  (Figs.  311, 
312,  313,  314,  315  and  316). 

Sharpe  recommends  a  vertical  incision  beginning  just  above  the  posterior 
portion  of  the  zygoma  and  going  upward  three  inches.  This  would  seem  to 
involve  the  regions  that  are  nearer  to  the  lower  Rolandic  area  than  the  straight 
incision  that  is  directed  slightly  backward. 

An  important  step  in  the  operation  is  to  remove  the  bone  in  the  thin  tem- 
poral region  of  the  skull  as  far  toward  the  base  of  the  skull  as  possible.  The 
operation  will  not  be  satisfactory  for  tumors  below  the  tentorium  and  here  an 
occipital  incision  and  decompression  must  be  made  according  to  the  method 
already  described  for  exposing  the  cerebellum.  In  patients  who  are  right- 
handed,  the  speech  center  is  supposed  to  be  on  the  left  side  of  the  brain,  so  it 
is  best  to  make  the  decompression  on  the  right  side  unless  there  is  some  cerebral 
lesion  or  other  reason  for  performing  the  operation  on  the  left  side.  In  left- 
handed  patients  the  speech  center  is  on  the  right  side  of  the  brain. 

OPERATIONS  ON  THE  GASSERIAN  GANGLION 

Instead  of  removing  the  gasserian  ganglion  when  a  radical  operation  for 
tic  douloureux  is  indicated,  it  is  best  to  do  what  is  called  a  physiologic  extir- 
pation, and  divide  or  avulse  the  posterior  sensory  root  of  the  gasserian  ganglion. 
This  operation  was  first  suggested  by  Spiller,  of  Philadelphia,  and  was  performed 
by  Charles  H.  Frazier,  in  1901.  Tlie  extirpation  of  the  ganglion  is  not  only 
a  somewhat  more  difficult  operation  than  division  of  its  posterior  sensory  root, 
but  is  also  more  likely  to  be  followed  by  trophic  disturbance  to  the  eye.  This 
may  be  due  to  the  fact  that  sympathetic  nerves  from  the  neck  to  the  eye  pass 
through  the  front  and  inner  portions  of  the  ganglion  and  are  not  disturbed  by 
division  of  the  posterior  sensory  root. 

Frazier  advises  the  sitting  posture  for  this  operation.  If  this  cannot  be 
done,  the  patient  should  at  least  be  placed  in  the  reversed  Trendelenburg  posi- 
tion. A  skin  flap,  according  to  Frazier,  is  made  with  the  hinge  along  the  anterior 
hair-line.  This  is  done  by  making  a  straight  incision  from  a  point  over  the 
upper  border  of  the  zygoma  about  its  middle  backward  to  the  posterior  extrem- 
ity of  the  zygoma,  then  straight  upward,  then  forward  to  the  hair-line  (Fig.  317). 
The  flap  of  skin  is  turned  forward  and  sutured  to  the  towel  surrounding  the 
wound.  A  flap  of  fascia  and  muscle  is  formed  which  hinges  backward  and  is 
sutured  to  the  towel  posteriorly.  This  latter  flap  does  not  go  as  far  forward 
as  the  skin  flap  and  the  margin  of  muscle  and  fascia  anteriorly  is  separated  from 
the  skull  and  sutured  to  the  under  surface  of  the  skin  flap.  In  this  manner 
satisfactory  exposure  of  the  temporal  bone  is  obtained  without  the  use  of  retrac- 
tors. The  skull  is  perforated  by  a  burr  and  the  opening  enlarged  with  rongeur 
forceps,  taking  care  to  extend  the  bony  opening  well  down  to  the  base  of  the 
skull  (Fig.  318).  An  area  of  bone  about  one  and  one-quarter  to  one  and  one- 
half  inches  in  diameter  is  removed.    The  dura  is  gently  elevated  from  the  middle 


284 


OPERATIVE   SURGERY 


fossa  of  the  skull  until  the  foramen  spinosum  is  approached.  Here  the  middle 
meningeal  artery  is  seen.  The  dura  is  elevated  both  in  front  and  behind  the 
artery  and  the  artery  is  tied  with  silk  or  the  foramen  spinosum  is  plugged  with 


Fig.    317. — I^ines    shuwing    the    incision    in    tlu-    ..I'eratiun    of    Frazier    for    removal    'A    tlit     -..ii-oiy    root    of 

the  gasserian  ganglion. 


Fig.    318. — The    fiaps   are   reflected    and   the   skull    is    perforated    with    a   burr. 


bone  wax,  a  small  piece  of  temporal  muscle,  or  a  small  piece  of  gauze  or  cotton. 
If  the  artery  cannot  be  tied,  plugging  the  foramen  spinosum  will  usually  con- 
trol it.  The  separation  of  the  dura  from  the  skull  is  then  continued  until  the 
foramen  ovale,  containing  the  third  division  of  the  fifth  nerve  is  seen.     Any 


SCAT.P,    SKULL,    AND    URAIN 


285 


bloedint^'  points  are  coul rolled  by  pressure,  pressing  small  pledgets  of  dental 
cotton  over  the  bleeding  spots  and  leaving  them  in  position. 

The  third  division  ol'  Ihe  tifth  nerve  is  followed  up  to  the  posterior  portion 
of  the  ganglion  and  an  ineision  is  made  into  the  dura  propria  over  the  posterior 
part  of  the  ganglion.  This  exposes  the  sensory  root.  The  fibers  of  the  posterior 
root  are  recognized  and  isolated,  taking  care  to  get  the  inner  as  well  as  the 
outer  portion  of  the  fibers.  All  of  the  fibers  of  the  posterior  sensory  root  are 
gathered  with  a  small  blunt  hook  and  gentle  traction  is  made  which  avulses  the 
fibers  from  their  origin  (Fig.  319). 

Adson-^  makes  an  incision  in  the  form  of  a  question  mark,  carrying  the 
long  end  down  in  front  of  the  ear.     The  incision  begins  one  and  a  quarter 


Fig.   319. — The  sensory   root  of   the   ganglion  is   exposed   and   is  about   to   be   avulsed. 

inches  posterior  to  the  external  angle  of  the  orbit  and  the  same  distance  above 
the  zygoma,  and  curves  backward  and  then  downward  in  front  of  the  ear. 
Recently  he  has  adopted  a  simple  straight  incision.  He  uses  a  special  re- 
tractor with  a  small  electric  light  at  its  end.  The  middle  meningeal  artery 
is  always  tied.  This  is  done  with  a  special  aneurism  needle  after  separating 
the  dura  in  front  of  and  behind  the  artery  (Fig.  320).  I  have  used  a  loop 
of  silver  wire  for  this  purpose,  the  silk  or  linen  ligature  being  placed  in  the 
loop  after  it  has  been  passed  around  the  artery.  Adson  does  not  uncover 
the  ganglion  but  incises  the  dura  propria  behind  the  ganglion  over  about  the 
middle  of  the  posterior  sensory  root  and  demonstrates  the  dural  opening 
through  which  this  root  goes  to  the  brain.    He  advises  cutting  the  fibers  of  the 


sSurg.,  Gynec.  &  Obst.,  Oct.,   1919,   pp.   334-339. 


286 


OPERATIVE    SURGERY 


posterior  sensory  root  instead  of  avulsing  tliem,  and  he  does  this  with  a  special 
guillotine  knife  which  is  slipped  over  the  fibers.  He  feels  that  division,  which 
is  all  that  is  necessary,  as  these  fibers  do  not  regenerate,  will  inflict  less  injury 
on   the   medulla   and   nuclei    in   the   neighborhood   of   the    origin    of    the   fifth 


Fig.   320. — In  the  operation  of  Adson  tlie  middle  meningeal   artery   is   tied  and  divided.      The   sheath   from 
the   posterior   sensory    root   is    exposed   and   the    brain   held    back    with   Adson's    retractor. 


Fig.   321.- — The   posterior  sensory   root   is   divided   in   its   sheath.      Insert   A    shows   the   normal   dural   opening 
for  the  sensory  root,  the  stump  of   this   root  having  been   shoved  back  into   the   dural   cavity. 

nerve,  than  will  avulsion  of  these  fibers.  He  has  had  a  few  cases  of  temporary 
facial  paralysis  following  avulsion,  but  none  following  division.  After  division 
of  the  fibers  the  proximal  stump  is  pushed  back  within  the  dural  cavity  and 
the  opening  in  the  dura  is  plugged  with  a  small  piece  of  temporal  muscle, 


SCAT.P,    SKULL,    AXD    BRAIN  287 

wliieli  Adsou  believes  lessens  the  leakage  of  cerebrospinal  fluid  (Fig.  321).  The 
wound  is  closed  iu  layers,  using  fine  tanned  catgut  for  the  muscle  and  fascia 
and  galea  of  the  scalp,  and  fine  silk  or  silkworm-gut  for  the  skin.  This  is  an 
excellent  operation. 

The  patient  leaves  the  bed  after  a  few  days.  The  eye  over  the  affected 
side  must  be  protected  during  convalescence  either  by  an  eye-sliield  or  by 
frequent  irrigation  of  the  eyelid  with  a  two  per  cent  boric  acid  solution.  If 
the  eye  is  protected  by  a  dressing  it  is  important  not  to  have  the  dressing 
press  on  the  lids,  for  this  in  itself  may  cause  injury  to  the  cornea.  Suturing 
the  lids  together  for  a  few  weeks  is  a  very  satisfactory  method  of  protecting 
the  cornea. 


CHAPTER  XVI 
OPERATIONS   ON   THE   SPINE 

The  operation  on  the  spine  that  is  most  frequently  performed  is  lumbar 
puncture.  This  may  be  done  for  diagnostic  purposes,  for  treatment  either  in 
removing  excessive  fluid  or  injecting  remedies,  or  for  the  administration  of 
spinal  anesthesia.  The  operation,  while  comparatively  simple,  is  by  no  means 
devoid  of  danger,  and  should  not  be  approached  without  the  proper  equip- 
ment of  instruments  and  a  correct  knowledge  of  the  operation. 

The  needle  used  by  Frazier  has  a  short  bevel  so  there  will  be  a  minimum 
amount  of  injury  to  the  nervous  structures  and  so  the  dura  can  be  penetrated 
with  but  little  chance  of  having  part  of  the  opening  of  the  needle  within  the 
dural  cavity  and  part  without.  A  needle  with  a  long,  slender  sloping  bevel 
may  cause  £ome  of  the  injected  fluid  to  leak  outside  the  dura,  even  though  some 
of  it  may  reach  the  dural  cavity.  It  is  best  to  have  the  needle  of  platinum, 
though  this  is  not  essential.  The  diameter  of  the  lumen  of  the  needle  is  about 
one  millimeter.  The  other  instruments  depend  upon  what  is  expected  to  be  ac- 
complished by  the  lumbar  puncture.  If  it  is  for  diagnostic  purposes  a  three- 
way  stop-cock  attached  to  the  needle  or  encorporated  in  the  needle  facilitates 
the  measurement  of  the  pressure  of  the  cerebrospinal  fluid.  A  manometer, 
preferably  the  Landon  mercurial  manom.eter,  should  be  ready.  In  addition 
there  should  be  two  test  tubes,  two  small  graduates  and  a  hypodermic  syringe, 
as  well  as  the  connecting  tubes  between  the  manometer  and  the  spinal  needle. 
When  the  instruments  have  been  properly  sterilized  and  the  lower  portion  of  the 
lumbar  spine  has  been  painted  with  tincture  of  iodine,  the  tip  of  the  spinous 
process  of  the  fourth  lumbar  vertebra  is  found  by  stretching  a  sterile  towel 
from  the  tip  of  the  crest  of  one  ileum  to  the  tip  of  the  crest  of  the  other.  This 
line  marks  the  S23inous  process  of  the  fourth  lumbar  vertebra  and  the  best 
point  for  puncture  is  immediately  below  this. 

The  operation  should  be  performed  with  gloves  and  with  the  same  aseptic 
care  that  would  attend  any  surgical  operation.  The  skin  may  be  infiltrated  with 
one-half  of  one  per  cent  novocain  solution  and  a  short  incision  made  with  the 
point  of  a  tenotome  or  a  Hagedorn  surgical  needle.  This  makes  it  easier  to 
insert  the  spinal  needle  which  has  a  short  bevel,  and  at  the  same  time  de- 
creases the  possibility  of  the  needle  carrying  into  the  spinal  cord  germs  from 
the  deeper  layers  of  the  skin.  The  patient  bends  forward  as  far  as  possible. 
The  needle  is  inserted  in  the  midline,  half-way  between  the  spinous  process  of 
the  fourth  and  that  of  the  fifth  lumbar  vertebra.  If  the  patient  is  suspected  of 
having  a  brain  tumor  the  puncture  should  always  be  done  in  the  horizontal 
position,  which  is  the  safest  under  any  circumstances.     The  needle  is  pushed 

288 


THE   SPINE  289 

straiiilit  imvnrd  and  sliiihtly  ujnvard  almost  perpciidirular  to  the  plane  of  the 
skin,  though  with  a  slight  tendency  u])ward.  As  it  passes  through  the  ligaments 
of  the  spine  considerable  resistance  is  felt.  When  it  reaches  the  dura  the  sen- 
sation is  often  obtained  as  though  the  needle  were  puncturing  parchment.  Here 
it  should  be  shoved  forward  very  gently  and  the  stylet  withdrawn. 

If  the  needle  is  graduated,  some  help  is  afforded  in  estimating  the  distance 
of  the  point  of  the  needle  from  the  dura  of  the  spine,  though  the  depth  of  the 
dura  is  rather  variable.  In  infants  and  children,  the  distance  from  the 
skin  to  the  dura  is  about  one  inch.  In  thin  frail  individuals  it  will  vary 
from  one  and  three-quarters  to  two  and  one-half  inches.  In  muscular  patients  it 
will  be  about  two  and  one-half  to  three  and  one-half  inches,  whereas  in  very 
stout  persons  it  may  be  half  an  inch  deeper. 

No  advantage  can  come  from  inserting  the  needle  to  the  side  of  the  mid- 
line, as  is  advocated  by  some  authorities.  First  of  all,  it  is  impossible  to  tell 
the  exact  depth  of  the  dura  from  the  skin  and  therefore  the  needle  cannot 
be  entered  accurately  except  in  the  posterior  midline  of  the  dura.  On  either  side 
of  the  midline  it  is  likely  to  encounter  more  bleeding  vessels  than  it  would  in 
the  midline,  and  in  addition  there  is  greater  possibility  of  injuring  the  fixed 
portions  of  the  spinal  roots  that  are  emerging  from  the  dura. 

After  the  stylet  has  been  removed  the  further  procedure  will  depend  upon 
the  indications  for  lumbar  puncture.  If  for  diagnostic  purposes,  the  first  thing 
to  be  determined  is  the  pressure  of  the  cerebrospinal  fluid.  The  mecurial 
manometer  of  Landon,  as  used  in  Frazier's  clinic,  is  probably  the  most  satis- 
factory instrument  for  this  purpose. 

"What  is  the  normal  pressure  of  the  cerebrospinal  fluid  is  a  subject  that 
evokes  much  discussion.  The  pressure  fluctuates  under  normal  and  abnormal 
conditions.  Slight  variations  are  caused  by  inspiration  and  expiration,  by  the 
blood  pressure,  by  the  position  of  the  patient,  and  by  coughing  or  forced 
muscular  movement.  While  Frazier  has  found  that  a  transitory  fall  in  the 
pressure  of  the  cerebrospinal  fluid  is  caused  by  closure  of  the  carotids,  obstruc- 
tion of  the  venous  circulation  causes  a  rise  in  pressure.  Variations  from  72 
millimeters  of  water  to  200  millimeters  of  water  are  given  as  extremes  of  normal 
of  the  cerebrospinal  fluid  by  different  authorities.  With  the  mercurial  manom- 
eter of  Landon  anything  over  twelve  millimeters  of  mercury  is  regarded  as  sus- 
picious and  twenty  millimeters  as  distinctly  pathologic.  Frazier^  regards  the 
normal  pressure  with  the  patient  quiet  and  on  the  side  as  about  8  millimeters  of 
mercury. 

After  the  pressure  has  been  obtained  the  stop-cock  can  be  switched  to 
the  sterile  graduate,  and  enough  fluid  collected  for  examination.  For  an  or- 
dinary examination,  Wassermanu,  cell  count,  albumin,  sugar,  and  bacterial  cul- 
tures, 5  c.c.  are  sufficient.  This  should  be  slowly  withdrawn.  If  the  fluid  is 
under  great  pressure  and  the  object  of  the  lumbar  puncture  is  to  decrease  this 
pressure,  more  fluid  is  withdrawn  and  the  measurement  of  the  pressure  occa- 


iprazier,  C.  H.:      Surgery  of  the  Spine  and  Spinal  Cord,  New  York,   1918,  D.  Appleton  &  Co.,  p.   151. 


290  OPERATIVE    STRGERY 

sionally  taken  to  indicate  when  the  M'ithdrawal  should  cease.  If  the  flow  is 
too  rapid  it  is  checked  at  intervals.  If  it  is  intended  to  give  spinal  anesthesia, 
the  amount  withdrawn  should  be  equivalent  to  the  volume  of  the  anesthetic 
mixture  to  be  injected.  Many  operators  prefer  to  withdraw  a  definite  amount 
of  the  cerebrospinal  fluid  and  dissolve  the  previously  sterilized  anesthetic  tablet 
in  the  w^ithdrawn  cerebrospinal  fluid.  This,  of  course,  adds  to  the  specific 
gravity  of  the  reinjected  fluid  and  this  objection  has  been  overcome  by  Daniel 
A.  Orth,-  by  dissolving  the  anesthetic  in  a  sufficient  amount  of  distilled  water 
to  make  the  solution  have  the  same  specific  gravity  as  the  cerebrospinal  fluid. 
The  amount  of  cerebrospinal  fluid  equivalent  to  the  volume  of  the  anesthetic 
solution  is  withdrawn  permanently  and  then  a  small  amount  of  cerebrospinal 
fluid  is  withdrawn,  mixed  with  the  anesthetic  solution,  and  reinjected  into  the 
spinal  canal. 

LAMINECTOMY 

The  operation  by  which  tumors  or  other  lesions  of  the  spinal  cord  are 
approached  is  laminectomy,  which  consists  in  the  removal  of  the  spinous  proc- 
esses and  the  lamina?  of  the  vertebrte.  The  location  of  the  lesion  in  the  spinal  cord 
should,  of  course,  be  very  accurately  ascertained.  If  the  lesion  is  supposed  to  be 
a  tumor,  it  is  likely  to  be  higher  in  the  canal  than  anticipated.  After  marking 
the  vertebra  Avhich  lies  immediately  over  the  lesion,  its  spinous  process  is 
indicated  by  touching  the  skin  over  it  with  nitrate  of  silver.  This  is  done 
the  day  before  the  operation.  The  incision  through  the  skin  is  crescentic, 
beginning  in  the  midline  a  vertebra  above  the  highest  vertebra  that  is  to  be 
removed,  curving  outw^ard  and  returning  to  a  vertebra  beloAV  the  low-est  ver- 
tebra to  be  removed  (Fig.  322).  This  flap,  including  fat  and  superficial  fascia, 
is  reflected  to  give  ample  exposure  to  the  spine.  The  margins  of  the  flap  are 
covered  with  gauze  wrung  out  of  salt  solution  and  an  incision  is  made  in  the 
intervertebral  fascia,  which  begins  in  the  midline  at  the  tip  of  the  spinous  proc- 
ess just  above  the  first  one  to  be  removed  and  follows  closely  the  sides  of  those 
spinous  processes  to  be  removed,  terminating  in  the  midline  just  below  the 
last  spinous  process.  These  incisions  are  made  first  on  one  side  of  the  spine  and 
then  on  the  other,  hugging  the  bone  quite  closely.  The  muscle  is  separated  from 
the  spinous  processes  and  the  lamina  by  a  broad  chisel  which  hugs  the  bone  as 
closely  as  possible  and  in  this  way  not  only  prevents  bleeding,  but,  by  stripping  up 
some  periosteum  and  fragments  of  bone,  leaves  tissue  from  which  later  on  bony 
elements  of  the  spine  are  sometimes  regenerated.  All  of  the  periosteum 
cannot  be  removed,  though  some  of  it  with  small  chips  of  bone  can  be  sepa- 
rated by  the  chisel.  The  bleeding  is  greatly  lessened  by  keeping  close  to  the 
bone  and  when  too  free  is  controlled  by  packing  the  wound  with  gauze  and 
placing  retractors  over  the  gauze  in  a  manner  not  only  to  expose  the  spine 
but  to  use  pressure  on  the  bleeding  surface.     An}"  large   spurting  point   is 


-Surgical   Clinics   of  Chicago,    Feb.,    1919,   pp.   201-213. 


THK    RIMNE 


291 


controlled   by   ^vllip|>illii■   '1    "vcr   with   caliiul.     Self-retainiiig'   retractors   may 
be  used  but  llie  ortliiiary  hand  retractor  is  usually  satisfactory. 

The  interspinous  ligaments  are  separated  Avitli  a  knife  both  above  and 
below  the  spinous  i)roce.ss,  several  of  whieh  are  removed  with  bone  for- 
ceps. 4Mie  lamina'  are  removed  with  roni^enr  forceps  (Fig.  323).  In  the 
lower  part   of   the   spine,   in   the   lumbar  region,   it  is   sometimes   difficult   to 


Fio-.    322. — The   incisiuu    lor  laminectomy   according   to    Frazier. 


find  an  opening.  Here,  if  a  small  rongeur  forceps  cannot  be  insinuated  un- 
der a  lamina,  an  opening  may  be  made  with  a  burr  as  in  the  skull  and  enlarged 
Avith  a  DeVilbiss  forceps  until  sufficient  bone  has  been  removed  to  enable 
the  rongeur  forceps  to  be  used.  Care  is  taken  not  to  injure  the  dura  and 
the  cord  during  these  manipulations.  Before  the  dura  is  opened  all  bleeding 
points  are  stopped.  Those  in  the  bone  can  be  controlled  by  the  application 
of  bone  wax.    At  other  points  either  pressure  or  whipping  over  with  catgut 


292 


OPERATIVE   SURGERY 


will  suffice.  Before  opening  the  dura  the  wound  should  be  completely  cov- 
ered with  fresh  gauze  wrung  out  of  salt  solution.  The  dura  is  carefully 
inspected  for  irregularity  of  contour  or  color  before  it  is  opened.  It  is  caught 
up  with  the  point  of  a  small  curved  needle  held  in  hemostatic  forceps  and  in- 
cised, or,  as  practiced  by  Frazier,  two  small  black  silk  sutures  are  inserted  on 
each  side  of  the  midline  and  the  incision  is  made  between  them.     These  su- 


Fig.    323. — Spinous  processes  have   been   partlj^   removed. 

tures  should  not  perforate  the  dura.  The  incision  is  carried  down  through 
the  dura  with  the  intention  of  not  cutting  the  arachnoid  (Fig.  324).  If  the 
arachnoid  is  not  wounded  it  bulges  into  the  wound  like  a  fetal  membrane 
before  the  waters  have  broken.  A  groove  director  is  inserted  and  the  dura  is 
further  opened  both  upward  and  downward  from  this  midpoint.  Two  more 
sets  of  small  silk  sutures  are  inserted  at  the  distal  ends  of  the  incision  in  the 
dura  and  are  clamped  by  hemostatic  forceps  at  a  sufficient  distance  from  the 


THE    SPINE 


293 


M'oiiiul  not  to  be  in  the  way.  A  small  cylinder  of  cotton  about  one-third  of 
an  inch  in  iliainotor  is  placed  on  eaeh  side  of  the  incised  dura  at  the  depth  of  the 
wound  to  eateh  any  blood  that  may  accumulate.  When  this  cotton  roll  becomes 
saturated  with  blood  it  is  replaced  by  a  fresh  one    (Fi<?.  325).     It  is  highly 


Fis?.   3J4. — The  dura   of  the   cord   is  incised. 


important  throughout  the  operation  to  protect  the  cord  and  the  cavities  con- 
taining the  cerebrospinal  fluid  from  blood.  Pulsation  or  absence  of  pulsa- 
tion and  the  amount  of  tension  of  the  cerebrospinal  fluid  is  observed  before  the 
arachnoid  is  opened  as  well  as  before  incising  the  dura.  The  arachnoid  space 
is   opened   and   cerebrospinal  fluid   permitted   to    escape.      The    cord    should 


294 


OPERATIVE    SURGERY 


be  handled  with  the  greatest  gentleness.  The  position  of  the  patient  should 
be  such  that  the  wound  is  approximately  at  the  highest  point  and  the  pa- 
tient should  be  well  under  the  anesthetic  so  tbat  no  attempt  at  coughing  or 
vomiting  will  cause  an  undue  loss  of  cerebrospinal  fluid.  The  cord  should 
not  be  sponged  with  a  dry  sponge  and  should  be  manipulated  with  the  great- 
est delicacy  throughout. 

If  a  tumor  is  to  be  removed  and  it  does  not  present  readily  into  the  wound, 
the  cord  is  gently  manipulated  by  using  traction  upon  the  dura  on  the  side 
to  be  exposed.  The  cord  or  its  roots  should  never  be  grasped  until  definitely  as- 
sured tliat  this  is  necessary.    If  a  tumor  presents  under  the  dura  and  is  adherent 


Fig.    325. — The   dura   has   been    incised   and    the    cord    is    e.xposed. 

to  the  dura,  a  portion  of  this  membrane  may  be  removed  along  with  the 
growth.  If  the  tumor  is  within  the  substance  of  the  spinal  cord  its  removal 
is  a  matter  of  the  greatest  delicacy.  An  incision  is  made  over  the  tumor  as 
near  the  midline  of  the  cord  as  possible  and  with  a  very  sharp  thin  knife. 
Often,  after  waiting  a  few  minutes,  the  tumor  gradually  extrudes  itself. 
Some  operators  advise  closing  the  muscle,  fascia  and  skin,  and  doing  a  second 
operation  a  few  weeks  later,  claiming  that  nature  can  extrude  the  cord  in 
this  way  with  less  injury  than  the  operator  will  inflict.  If,  however,  the 
tumor  can  be  gently  raised  with  a  minimum  of  trauma  it  may  be  removed  at 
this  time.  If  bleeding  is  caused  by  the  efforts  at  removal,  these  efforts 
should  cease  at  once  and  the  operation  is  left  for  another  stage  or  else  en- 
tirelv  abandoned. 


THE    SriNE 


295 


]E  the  ()l),)\'c't  of  file  lainiiu'ctoiny  is  to  section  the  posterior  nerve  roots 
for  the  relief  of  pain,  or  to  relieve  spastic  conditions,  the  nerve  roots  that 
are  intended  to  be  removed  are  identified  and  divided  with  a  sharp  scissors. 
Not  infreqnently  a  small  vessel  iiia\-  l)e  eiiconntered  and  this  is  best  controlled 
by  liu'aliiiu'  llie  roots  with  very  tine  silk  and  dividinu'  the  root  l)etween  the 
lig'atures.  If  the  silk  is  exceedingly  fine  it  will  cnt  through  the  soft  structure  of 
tlie  nerve  and  hold  only  the  blood  vessels.  This,  of  course,  cannot  be  done 
in  the  peripheral  nerves,  as  the  surrounding  fascia  and  sheath  of  the  nerve 
protect  the  fibers  and  prevent  them  from  being  cut  through  Avith  the  ligature. 

It  must  be  recognized  that  the  spinal  cord,  particularly  that  part  ex- 


Fig.    326. — The   dura   is  sutured. 

posed  posteriorly,  consists  largely  of  very  sensitive  sensory  fibers,  and  un- 
less carefully  luanipulated  not  only  is  injury  done  to  the  cord  but  shock 
is  produced.  The  cortex  of  the  brain  while  made  of  delicate  structures  has 
but  little  if  au}^  sensation,  and  when  manipulated  shows  but  little  shock.  This, 
however,  is  not  true  of  the  spinal  cord.  Frazier  suggests  what  he  calls 
the  stovain  block  in  which  he  applies  small  pledgets  of  cotton  soaked  in  one 
cubic  centimeter  of  four  per  cent  stovain  solution  at  the  upper  portion  of 
the  exposed  cord,  tucking  it  snugly  betAveen  the  cord  and  the  dura. 

After  accomplishing  the  desired  manipulation  for  the  lesion  for  which 
the  operation  is  done,  the  pledgets  of  cotton  are  removed  and  every  bleeding 
point  about  the  dura  or  arachnoid  is  controlled.  The  dura  is  sutured  with  a 
continuous  suture  of  fine  tanned  catgut  or  fine  silk  (Fig.  326).     Interrupted 


2n6  OPERATIVE    SL^RGERY 

sutures  of  stout  silkworm-gut  are  placed  well  beyond  the  margins  of  the  skin 
wound  through  the  fascia  and  deep  muscles  of  the  back  but  are  not  tied.  The 
muscles  of  the  back  are  approximated  Avith  a  continuous  suture  of  tanned  cat- 
gut and  the  fascia  with  a  continuous  lock  stitch  of  tanned  catgut.  The  skin 
is  closed  with  a  continuous  suture  of  fine  tanned  catgut  or  fine  silk.  The 
interrupted  sutures  of  silkworm-gut  are  tied  over  a  roll  of  gauze  to  prevent 
cutting  the  skin.  No  provision  is  made  for  drainage.  A  flat  sterile  cotton 
pad  is  placed  on  the  bed  opposite  the  wound  and  the  patient  is  returned  to  bed 
without  any  unusual  restrictions. 

Osteoplastic  methods  of  laminectomy  are  not  satisfactory  and  the  func- 
tion of  the  spine  after  laminectomy  done  in  the  manner  described  is  good. 

SPINA  BIFIDA 

Operations  for  spina  bifida  should  not  be  undertaken  without  a  knowl- 
edge of  the  pathology  of  the  disease  and  the  different  types  of  the  defect. 
A  bifid  spine  is,  of  course,  a  congenital  defect  and  may  vary  from  a  simple 
hernia  of  the  meninges  of  the  spinal  cord  to  the  protrusion  of  practically 
all  of  the  elements  of  the  cord  through  an  extensive  defect  in  the  posterior 
portion  of  the  spinal  canal.  The  different  types  of  spina  bifida  may  be  classed 
as:  (1)  meningocele,  in  ivhich  the  meninges  and  chiefly  the  dura  of  the 
spinal  cord  constitute  the  protrusion;  (2)  myelocele,  in  which  there  is  grave 
involvement  of  the  spinal  cord  and  which  is  probably  the  most  serious  form 
of  spina  bifida;  (3)  myelocystocele,  or  syringomyelocele,  in  which  fluid  ac- 
cumulates within  the  substance  of  the  cord  itself;  and,  (4)  spina  bifida  oc- 
culta, in  which  there  has  been  a  defect  in  the  spine  but  no  protrusion. 

The  simple  meningocele  offers  the  best  prospect  for  successful  treatment 
by  operation.  In  this  variety  of  spina  bifida  there  is  a  defect  in  the  posterior 
IDortion  of  the  vertebra,  or  sometimes  in  the  vertebrae  and  dura,  in  which 
the  other  membranes  of  the  cord  protrude  if  the  dura  is  absent.  This  form,  which 
is  the  most  favorable  for  operation,  is  not  the  most  common  variety.  It  is  fre- 
quently found  in  the  sacral  region,  sometimes  in  the  cervical,  and  occasionally  in 
the  lumbar  or  thoracic  portion  of  the  spine.  The  sac  may  be  composed  of 
dura  alone,  or  of  dura  and  arachnoid,  or  only  of  arachnoid.  Usually  the 
dura  is  present.  Sometimes  in  the  lower  portion  of  the  spine  the  cauda  equina 
is  adherent  to  the  sac  wall,  though  it  is  usually  free.  The  skin  covering  of  the 
meningocele  type  of  spina  bifida  is  frequently  normal  or  at  any  rate  is  not  often 
ulcerated,  though  toward  the  summit  of  the  protrusion  the  skin  is  sometimes 
very  thin.  Not  infrequently  a  tumor,  as  a  fibroid  or  dermoid  cyst,  rests 
upon  the  meningocele.  Any  fatty  or  fibroid  tumor  that  arises  in  the  midline 
of  the  back  should  ahvays  be  suspected  of  being  connected  with  a  spina  bi- 
fida. 

The  second  form,  myelocele  or  meningomyelocele,  is  the  most  hopeless 
type  of  this  disease,  because  the  spinal  cord  and  its  membranes  and  the  skin 
are  all  involved.     The  arrest  of  development  of  this  type  of  spina  bifida  oc- 


THE    SPINE 


297 


curs  very  early  in  I'elal  life  aiul  the  posterior  wall  of  the  iienral  tube  and 
the  adjoininii'  membra  ties  do  not  close,  so  there  is  a  direct  communication 
with  the  central  canal  of  the  cord.  The  fluid  collects  in  front  of  the  cord 
and  consequently  pushes  the  cord  backward.  The  sac  is  composed  of  pia  and 
the  flattened  cord,  or  the  cauda  equina  and  nerve  roots.  The  nerve  roots 
become  elongated  from  the  pressure  backward  of  the  cord.  This  type  of 
spina  bifida  always  has  a  characteristic  covering.  About  the  center  of  the 
protrusion  is  what  is  known  as  the  meduUo-vasculosa  area,  which  is  occupied 
by  granulations.  This  is  oval  in  shape  and  here  even  the  pia  is  lacking.  This 
portion  of  the  sac  is  formed  of  the  ventral  surface  of  the  central  canal  of 
the  cord.  Along  the  middle  is  usually  a  groove  which  shows  where  the 
cord  is  attached.  Just  without  this  central  or  medullary  zone  is  the  serous 
zone  or  epithelio-serosa  zone.  This  is  pink  and  very  thin  and  does  not  con- 
tain any  of  the  corium  of  the  skin.  External  to  this  and  surrounding  the 
outer  part  of  the  growth  is  what  is  known  as  the  dermic  zone,  composed 
of  slightly  thickened  skin. 

In  the  third  type,  myelocystocele,  or  syringomyelocele,  there  is  a  de- 
fect in  the  posterior  part  of  the  spinal  column  and  dura,  but  the  arachnoid, 
pia  and  epidermis  have  closed.  The  skin  is  usually  about  normal.  The  fluid 
is  in  the  central  canal  of  the  cord,  which  is  greatly  dilated.  The  cord  is  com- 
pressed so  that  portions  of  it  may  have  disappeared  and  the  nerve  roots  are 
greatly  stretched.  Naturally,  this  tumor,  as  a  rule,  has  a  broad  base,  is  soft  and 
not  so  tense  and  prominent  as  the  two  other  forms  that  have  been  described.  The 
skin  is  often  thick.  From  the  great  involvement  of  the  cord  in  this  and  in 
the  preceding  type,  there  usually  is  paralysis  or  club  foot  or  some  evidence 
of  injury  to  the  spinal  cord. 

In  the  fourth  type  of  spina  bifida,  spina  bifida  occulta,  there  are  symp- 
toms that  only  occur  from  tension  upon  the  cord.  This  is  the  result  of  an 
early  form  of  a  small  meningocele  type  and  the  connection  between  the 
skin  and  the  membrane  around  the  cord  still  holds,  though  the  sac  has 
disappeared.  As  the  patient  grows,  this  connection  does  not  grow  as  rapidly 
as  the  other  portions  of  the  body,  so  tension  is  made  by  this  band  upon  the 
structures  of  the  cord,  and  permanent  injury  to  the  cord  may  occur  on  ac- 
count of  this  traction. 

Whether  a  patient  suffering  with  spina  bifida  should  be  operated  upon 
for  this  defect  depends  upon  the  general  condition  of  the  patient  and  upon 
the  type  of  spina  bifida  present.  Even  in  the  meningocele  types,  which  are 
most  susceptible  to  operation,  if  there  is  an  accompanying  marked  hydro- 
cephalus, operation  should  not  be  done.  While  it  is  undoubtedly  true  that 
the  prime  defect  in  bifid  spine  is  lack  of  development  of  the  posterior  por- 
tions of  the  spinal  vertebrae,  it  is  probable  that  some  other  pathologic  in- 
fluence must  be  present  during  development  such  as  increased  pressure  of 
the  cerebrospinal  fluid.  If  hydrocephalus  is  also  present  and  the  sac  of  the 
meningocele  is  removed  there  is  no  safety  valve  left  to  take  up  any  unusual 
increase  in  the  pressure  caused  by  the  hydrocephalus. 


298 


OPERATIVE    SURGERY 


As  Frazier  has  remarked,  it  l)y  no  means  necessarily  follows  that  when 
a  hydrocephalus  develops  after  an  operation  for  spina  bifida  the  relation 
is  one  of  cause  and  effect,  because  hydrocephalus  has  devloped  in  infants 
with  spina  bifida  who  have  not  been  operated  upon.  It  seems  good  surgical 
judgment,  however,  not  to  operate  upon  any  case  of  spina  bifida  with  marked 
hydrocephalus,  paralysis  of  the  sphincters,  or  of  both  lower  extremities.  It 
is  best  not  to  operate  upon  these  patients  until  after  they  have  attained  the 


Fig.    327. — The   sac   of   a   spina  bifida    has    been   exposed    by    a   U-shaped    flap 

of   incision    in    the    sac.      (Frazier.) 


The    dotted    lines    show    lines 


age  of  one  year,  at  least,  unless  there  is  a  threatened  rupture  of  the  sac  of 
the  meningocele  type. 

In  spina  bifida  occulta,  operation  should  be  done  as  soon  as  symptoms 
appear.  Here  the  indication  is  for  a  limited  laminectomy  and  division  of  the 
cord  or  band  that  is  causing  trouble. 

In  the  second  and  third  types,  myelocele  and  myelocystocele,  but  little 
hope  can  be  entertained  for  operation  of  any  kind  as  the  involvement  of  the 
cord  has  been  so  extensive  that  the  damage  to  the  spinal  cord  from  pressure 


THE    SPINE 


200 


Fig.   328. — Ths  stum]5  of  the  sac  is  being  sutured. 
(Frazier.) 


Fig.    329. — A    fascia    flap    is    formed    to    turn    onto 
the    stump   of   the    sac.      (Frazier.) 


Fig.  330. — The  lines  of  incision  for  a  flap  of 
fascia  to  still  further  cover  in  the  detecv. 
(Frazier.) 


Fig.  331. — The  flap  of  fascia  outlined  in  the 
preceding  figure  has  been  turned  down  and  is 
being   sutured   in   place.      (Frazier.) 


and  distortion  mnst  have  already  occurred.     Most  of  these  cases  die  early, 
within  the  first  year. 

If  operation  is  to  be  done  the  technic  should  be  selected  according  to 
the  type  of  spina  bifida.  If  the  growth  is  a  simple  meningocele  with  a  narrow 
base  it  may  be  operated  upon  liy  an  incision  a  little  to  one  side  of  the  center 


300 


OPERATIVE    SURGERY 


of  the  growth,  or  by  the  U-shaped  flap,  which  Frazier  prefers  (Fig.  327). 
After  exposing  the  sac  it  is  cut  aAvay.  The  incision  is  made  carefully  in 
order  to  be  certain  that  no  elements  of  the  cord  are  contained  in  the  sac. 
The  margins  of  the  sac  are  whipped  over  with  a  continuous  suture  of  fine 
silk  or  fine  tanned  catgut  (Fig.  328).  An  incision  in  the  fascia  just  ex- 
ternal to  the  margins  of  the  defect  -will  turn  a  flap  on  to  the  sutured  neck 
of  the  sac  (Fig.  329).  The  muscles  on  each  side  are  approximated  and, 
following  Frazier 's  technic,  a  flap  of  fascia  is  turned  down  with  its  hinge 
along  the  upper  margin  of  the  defect  and  sutured  to  the  edges  of  the  fascia, 
so  covering  the  sutured  muscles  (Figs.  330  and  331).  This  flap  of  fascia 
may  be  a  free  transplant  from  the  fascia  lata.     If  the  growth  is  a  larger 


Fig.   332. — Operation  of  Babcock  showing'  the  division  of  the  stumps   of  the   lamins  on  the  right   side   and 

tlie  proposed  line  of  division  on  the  left. 


one  or  if  elements  of  the  cord  are  contained  in  it,  an  effort  should  be 
made  to  locate  the  elements  of  the  spinal  cord  by  gentle  palpation  or  by 
transillumination  before  opening  the  sac. 

In  myelocj'stocele  or  myelomeningocele,  if  operation  is  considered,  the  diffi- 
culties of  dealing  with  the  sac  will  be  great. 

Where  a  number  of  vertebrte  are  involved  an  osteoplastic  operation  may 
be  indicated.  Babcock,  in  1910,  elaborated  a  technic  for  this  type  of  spina 
bifida.  After  freeing  the  sac,  excising  it  and  suturing  its  stump,  the  margins  of  the 
bony  canal  are  freely  exposed  and  the  stumps  of  the  laminae  on  each  side  are 


THE    Sl'lNK 


301 


J'l'acluTcd  by  a  Sattorlee  bone  l'()re('])s.  In  tliis  manner  two  flaps  are  formed 
eonsistinu'  ol'  l)one  and  til)i'()ns  tissue,  eacb  of  wliidi  is  attaelied  al)ov('  and 
below  (Fig.  o;]2).  They  are  sntnred  together  in  the  midline  with  taniied  or 
ehromic  calgnt.  Kelaxation  incisions  are  made  in  the  muscle  and  aponeu- 
rosis on  each  side  of  the  spine  to  permit  the  muscle  and  its  aponeurosis 
to  bo  sutured  together  in  the  midline  (Fig.  333).  The  skin  is  brought  together 
with  great  care,  as  it  is  often  thin  and  poorly  nourished.  Mattress  sutures  tied 
just  tightly  enough  to  approximate  the  skin  are  satisfactory  in  closing  the 
skin  wound  in  this  operation  (Fig.  334). 


Fig.    333, — The   deep   layers   of   tissue  containing   the    laminje   have   been   united   and   the    fascia   over   this   is 
brought   together   after   making   relaxation   incisions. 


If  it  is  impossible  to  bridge  the  defect  satisfactorily  by  either  of  the  two 
types  of  operation  mentioned,  then  bone  grafting,  using  the  method  of  Albee, 
may  be  considered.  This  may  be  necessary  in  wide  defects  in  the  lower  lumbar 
region.  Here  Albee  in  order  to  immobilize  the  spine  transplants  two  bone 
grafts  which  meet  at  an  apex  in  the  lumbar  vertebra  immediately  above  the 
deformity  and  separate,  forming  a  triangle,  with  the  other  ends  of  the  grafts  at 
each  side  of  the  base  of  the  sacrum.  The  technic  is  quite  similar  to  that  used 
in  bone  grafts  for  Pott's  disease  of  the  spine,   except  that  the  rudimentary 


302 


oim;uativk  strgkry 


spinous  processes  cannot  be  split.     Wlien  tliis  is  impossible  the  spinous  process 
is  denuded  and  the  bone  graft  fastened  to  the  rudimentary  spine. 

A  meningocele  that  is  sometimes  exceedingly  puzzling  is  the  kind  in  which 
the  defect  in  the  spinal  column  occurs  in  the  body  of  the  vertebra  and  not 
in  the  lamina.  In  such  an  instance  the  pelvis  may  be  lifted  with  a  cyst  that 
resembles  in  j)hysical  characteristics  an  adherent  ovarian  tumor.  If  there  is 
marked  pain,  or  particularly  if  there  are  nervous  symptoms  in  the  lower  ex- 
tremities, the  possibility  of  such  an  unusual  spina  bifida  should  be  borne  in 
mind.     If  the  defect  is  not  large,  treatment  could  probably  be  carried  out  by 


Fig.    334. — Section    showing    the    various    layers    of   tissues    that   are    sutured    in    the    operation    of    Babcock 

for  spina  bifida. 

excision  of  the  sac  and  ligation  of  its  neck,  together  with  transplantation  of 
fascia,  or  such  other  plastic  procedures  as  might  appear  to  be  indicated  in  the 
particular  case. 

During  any  operation  for  spina  bifida  the  patient  should  be  so  placed  that 
the  spina  bifida  is  the  highest  point,  so  there  will  be  but  little  tendency  for  the 
cerebrospinal  fluid  to  escape  during  the  operation.  It  is  wise  to  lay  these  patients 
on  the  abdomen  after  operations  and  not  on  the  back,  as  in  infants  or  very 
young  children  there  is  a  great  tendency  for  the  wound  to  be  infected  by  urine 
or  the  bowel  movements. 


CHAPTER  XVII 
OPERATIONS  ON  THE  NECK 

Some  operations  on  the  neck  have  already  been  described  nnder  the  head  of" 
surgery  of  the  blood  vessels  or  surger}-  of  the  nerves  and  will  be  found  in  tlie 
preceding  chapters. 

Operations  on  the  neck  should  not  be  undertaken  unless  the  operator  has 
a  thorough  practical  knowledge  of  the  anatomy  of  the  neck.  It  is  entirely  pos- 
sible for  one  with  but  little  knowledge  of  anatomy  to  do  certain  abdominal 
operations  satisfactorily,  though  familiarity  with  it  would  help  even  in  the 
abdomen.  In  the  neck,  hoAvever,  a  surgeon  who  is  unfamiliar  with  the 
structure  of  the  neck  can  hardly  hope  to  muddle  through  a  serious  operation 
without  meeting  disaster.  There  are  certain  general  principles  applicable  to 
operations  in  the  neck,  the  axilla  and  the  groin,  which  should  always  be  borne 
in  mind.  The  chief  dangers  are  from  ignorance  of  anatomy  and  the  inability 
to  meet  emergencies  promptly.  "When  an  extensive  neck  operation  is  under- 
taken, the  first  essential  is  a  satisfactory  and  thorough  exposure  of  the  parts 
involved.  The  large  vessels  and  the  nerves  should  be  identified.  It  is  best 
first  to  expose  and  identify  the  important  vessels  and  nerves  and  then  dissect 
away  from  them.  If  the  operator  is  in  dread  of  cutting  a  big  vessel  or  in- 
juring a  nerve  and  plans  his  dissection  to  avoid  these  structures,  he  will  either 
blindly  injure  them  or  else  he  will  do  an  incomplete  operation.  By  exposing 
the  important  vessels  and  nerves  first  and  becoming  familiar  with  them,  the 
difficulties  and  dangers  of  the  operation  are  greatly  reduced. 

Hemorrhage  is  often  thought  to  be  the  chief  danger  in  neck  operations. 
Bleeding  can  be  reduced  by  elevating  the  head  and  body  of  the  patient.  I  for- 
merly employed  the  sequestration  anemia  of  Dawbarn,  but  finding  that  the 
patients  did  not  do  well  toward  the  end  of  a  tedious  operation  I  abandoned  it. 
As  has  been  discussed  in  a  previous  chapter  (p.  57),  sequestration  anemia 
produces  shock. 

If  the  operation  does  not  involve  entrance  into  the  mouth,  pharynx,  or 
air  passages  the  patient  should  be  well  under  the  anesthetic,  because  in  the 
early  stages  of  anesthesia  there  is  great  congestion  of  the  head  and  neck  and 
considerable  blood  may  be  lost  from  the  excessive  congestion. 

The  incision  in  the  skin  is  undermined  along  the  edges  to  secure  the  bleed- 
ing points  at  a  distance  from  the  edges  of  the  cut  skin.  Every  bleeding  point 
is  clamped  and,  if  possible,  vessels  are  doubly  clamped  before  being  divided. 
Dissection  about  the  internal  jugular  vein,  about  the  base  of  the  neck,  with 
the  patient's  head  elevated  carries  the  danger  of  opening  the  veins  and  of 
aspiration  of  air  into  the  veins.  This  is  alM^ays  a  serious  accident  and  may 
be  fatal. 

303 


304  OPERATIVE    SURGERY 

If  such  an  accident  occurs  the  opening  sliould  be  promptly  closed  by  a  wet 
sponge  or  by  the  finger  and  the  wound  flooded  with  salt  solution.  The  veins 
should  be  compressed  on  the  central  side  of  the  wound.  If  the  injury  to  the  vein 
is  inaccessible,  the  wound  is  packed  with  gauze  wrung  out  of  salt  solution 
and  left  in  position  for  four  days  when  the  gauze  is  gradually  removed  while 
keeping  the  wound  flooded  with  salt  solution.  Occasionally,  from  an  old  infection 
or  from  broken  down  glands,  small  veins  become  infiltrated  and  stiff  and  when 
cut  do  not  collapse  promptly.  Here  when  a  hissing  sound  is  heard,  which 
is  peculiar  to  the  aspiration  of  air,  the  suspected  point  is  at  once  compressed 
with  the  finger,  or  clamped,  or,  if  it  is  impossible  to  locate  the  wounded  vein, 
a  compress  of  wet  gauze  is  applied. 

While  -dissecting  in  the  neck  it  is  always  safer  to  clamp  doubly  before 
dividing  any  strand  of  tissue  that  may  be  a  vein.  The  late  J.  B.  Murphy  when 
doing  a  dissection  of  the  neck  exposed  the  lower  part  of  the  wound  first  and 
placed  a  small  pack  of  gauze  which  made  pressure  upon  the  internal  jugular 
vein  and  so  distended  it  that  it  was  easily  recognized  during  the  operation. 
The  danger  of  hemorrhage  from  a  wound  to  the  internal  jugular  is  far  less 
than  of  aspiration  of  air,  which  is  always  a  serious  occurrence.  The  struc- 
tures being  removed  during  dissection  of  the  neck  should  not  be  pulled  upon 
too  forcibly  while  being  cut  unless  they  have  been  previously  relaxed  and  the 
veins  which  run  to  the  structures  have  been  given  an  opportunity  to  fill  with 
blood.  Dissection  around  the  large  vessels  should  be  done  as  far  as  possible 
with  a  sharp  knife,  though  gauze  dissection  may  be  employed  after  the  vessels 
are  freed.  A  dull  knife  will  pull  and  hack  tissue  and  it  is  impossible  to  tell 
how  much  force  it  is  necessary  to  apply  to  each  stroke  of  the  knife. 

In  neck  operations  the  adjacent  lungs  and  pleura  at  the  base  of  the  neck 
must  also  be  borne  in  mind.  On  the  left  side  at  the  root  of  the  neck  the  thoracic 
duct  may  be  injured  while  dissecting  in  this  region. 

CYSTIC  HYGROMA  AND  CONGENITAL  CYSTS 

Hydrocele,  or  cystic  hygroma,  of  the  neck  is  lined  with  endothelium  and 
is  almost  always  in  the  lower  part  of  the  neck  behind  the  sternomastoid 
muscle.  This  growth  has  an  intimate  connection  with  the  internal  jugular 
vein  and  is  developed  from  embryonic  lymphatic  tissue.  It  is  quite  different 
from  the  cystic  tumors  in  the  floor  of  the  mouth,  so-called  ranula?,  or  in  the 
region  of  the  submaxillary  gland.  If  a  hygroma  is  not  large  and  there  are 
no  pressure  symptoms,  simple  aspiration  with  compression  or  the  application 
of  x-ray  or  radium  may  be  tried.  If  extirpation  is  decided  upon  it  will  frequently 
be  found  impossible  to  remove  all  of  the  sac,  and  extirpation  of  a  portion  of  the 
sac,  packing  the  rest  with  gauze,  is  often  all  that  can  be  done.  Sometimes  the  sac 
may  be  opened  and  sutured  to  the  edges  of  the  skin  and,  after  evacuating  the  con- 
tents, packed  with  gauze,  which  is  removed  every  few  days  until  the  wound  grad- 
ually closes.  Before  packing  the  sac  it  may  be  swabbed  with  pure  carbolic  acid 
followed  by  alcohol. 


THE    NECK  305 

Braiu'liial  cysts,  or  braiicliial  fistulas,  result  from  an  incomplete  closure  of 
the  l)ranchial  clcfls.  AVlicn  the  branchial  cyst  ruptures  through  the  skin 
a  iislula  is  formed.  A  frecpuMit  opening  for  this  fistula  is  along  the  lower 
portion  of  the  sternomastoid  muscle,  or  the  opening  may  be  higher  up  close 
to  the  angle  of  the  jaw,  depending  upon  the  cleft  from  which  the  branchial 
fistula  was  derived.  A  branchial  fistula  may  be  complete,  when  it  extends 
from  the  skin  of  the  neck  to  the  pharynx  or  esophagus,  or  incomplete  when 
a  blind  one.  Sometimes  it  will  be  blind  for  a  short  distance  but  the  end  of  the 
fistula  Avill  be  closely  attached  to  a  cord,  which  probably  means  that  this  por- 
tion of  the  fistula  has  been  obliterated.  This  cord,  however,  frequently  contains 
embryonic  rests  that  ma^'  cause  further  trouble  unless  the  cord  is  removed  along 
with  the  fistula.  The  dissection  for  removing  a  branchial  fistula  should  not  be 
lightly  undertaken.  Previous  to  the  operation  the  fistula  is  tested  to  see  whether  it 
is  complete  by  injecting  into  it  some  salt  solution  under  considerable  pressure,  and 
ascertaining  if  the  patient  can  recognize  that  the  salt  solution  goes  into  the  phar- 
ynx. If  it  does,  and  a  probe  can  be  made  to  follow  into  the  pharynx,  the 
dissection  is  much  easier  when  a  probe  is  inserted.  Frequently,  however, 
these  tracts  are  very  tortuous  and  are  incomplete.  Injecting  the  fistula  with 
methylene  blue  is  of  service  in  demonstrating  the  fistula  during  its  extir- 
pation. 

An  incision  is  made  along  the  anterior  border  of  the  sternomastoid  mus- 
cle including  the  orifice  of  the  fistula.  The  carotid  artery  and  the  internal  jugu- 
lar vein  are  first  exposed  and  identified.  The  fistula  with  a  small  amount  of 
skin  surrounding  its  orifice  is  dissected  from  beloAV  upward.  It  usually  fol- 
lows the  deep  vessels  of  the  neck  in  its  course  and  is  intimately  associated  with 
them,  particularly  in  the  upper  part  of  the  neck.  By  dissecting  the  vessels 
freely  and  exposing  them  carefully  the  chief  danger  is  avoided.  The  fistu- 
lous tract  must  be  followed  as  far  as  it  goes.  If  it  opens  into  the  pharynx,  F. 
Koenig  mobilizes  the  fistulous  tract  to  a  point  above  the  digastric  muscle  and 
then  by  blunt  dissection  separates  it  to  the  neighborhood  of  the  pharyngeal 
mucosa.  At  this  point  the  mouth  is  opened.  A  stout  probe  with  the  eye  at 
the  end  or  a  large  pedicle  needle  is  passed  through  the  wound  appearing  in 
front  of  the  lower  margin  of  the  tonsil.  The  probe  is  cut  down  upon  and  a  stout 
silk  thread  is  fastened  to  it.  This  is  withdrawn  into  the  neck  wound,  a  por- 
tion of  the  fistulous  tract  that  has  been  dissected  free  is  tied  to  the  thread 
and  by  this  means  pulled  into  the  mouth  and  fastened  with  a  few  stitches 
to  the  mucosa  in  front  of  the  tonsil,  the  redundant  part  being  cut  away.  The 
wound  in  the  neck  is  completely  closed. 

A  median  fistula  of  the  neck  usually  arises  from  the  nonobliteration  of  the 
thyroglossal  duct  which  leads  from  the  foram.en  cecum  on  the  tongue  to  a 
lower  point  in  the  neck.  This  duct  is  always  closely  connected  to  the  body 
of  the  hyoid  bone.  Occasionally  at  the  upper  portion  of  a  fistula  of  this  type 
a  tumor  containing  thyroid  tissue  occurs. 

The  results  of  operations  for  cysts  or  fistulas  of  the  thyroglossal  tract 


306 


OPERATIVE    SURGERY 


are  often  unsatisfactory  because  the  dissection  is  not  sufficiently  thorough. 
W.  E.  Sistrunk/  of  the  Mayo  Clinic,  describes  an  operation  for  excision  of 
thyroglossal  cysts  or  fistulas,  which  is  founded  on  sound  principles  and  gives 
excellent  results.  The  operation,  he  says,  is  usually  unsuccessful  unless  the 
whole  epithelial  lined  tract  from  the  cyst  to  the  foramen  cecum  in  the  tongue 
is  completely  removed.  The  portion  of  the  tract  around  the  hyoid  bone  -is 
difficult  of  dissection.  The  principle  of  the  operation  is  to  dissect  out  not 
only  the  tract  but  an  amount  of  tissue  for  about  an  eighth  of  an  inch  on  all 
sides  of  the  tract,  "coring"  it  out,  between  the  hyoid  bone  and  the  foramen 
cecum.     The  tract  lies  at  an  angle  of  forty-five  degrees  from  the  upper  sur- 


Fig.     335. — Cross     sec 


tion    showing    the    relations    of    the    cysts    and    fistulas     of    the    thyroglossal    tract, 
according  to  Sistrunk. 


face  of  the  center  of  the  hyoid  bone  in  the  midline  of  the  neck,  backward  and 
upward  to  the  base  of  the  tongue  (Fig.  335).  According  to  Sistrunk  a  trans- 
verse incision  two  inches  long  is  made  at  the  upper  level  of  the  hyoid  bone 
and  the  skin  and  platysma  are  reflected.  The  cyst  is  beneath  the  raphe 
connecting  the  sternohyoid  muscles  and  is  freed  from  the  surrounding  tissue 
up  to  the  hyoid  bone  where  the  tract  usually  passes  through  it.  The  mus- 
cles attached  to  the  center  of  the  hyoid  bone  are  freed  and  a  portion  of 
the  bone  about  a  quarter  of  an  inch  long  is  resected.  From  this  point  to 
the  foramen  cecum  there  is  no  attempt  to  dissect  out  the  thyroglossal  duct. 


lAnn.   Surg.,   February,   1920,   pp.   121-123. 


THE    NECK 


307 


Fio-.    336. — The    middle    segment    of    the    hyoid    bone    is    removed    and    the    thyroglossal    tract    is    dissected. 

(Sistrnnk.) 


Fig.    337. — The   dissection   has    been    completed,    and    the    foramen    cecum    is    exposed. 


but  the  tissue  is  removed,  as  a  core,  to  the  foramen  cecum  at  an  angle  of 
about  forty-tive  degrees  (Fig.  336).  The  core  is  about  a  quarter  of  an 
inch  in  diameter.  The  dissection  removes  a  portion  of  the  hyoid  bone, 
a  portion  of  the  raphe  joining  the  mylohyoid  muscles,  part  of  each  genio- 


308  OPERATIVE    SURGERY 

hj^oglossiis  muscle,  and  the  foramen  cecum  (Fig.  337).  The  wound  in  the 
mouth  is  closed,  the  genioh.y()gl()Ssus  muscles  are  brought  together  with  su- 
tures, and  the  soft  tissue  over  the  ends  of  the  hyoid  bone  are  approximated 
with  tanned  catgut  sutures  to  bring  the  ends  of  the  bone  together.  A  small 
drain  of  rubber  tissue  may  be  carried  to  this  point  and  the  skin  closed  around 
it. 

CERVICAL  RIBS 

Excision  of  a  cervical  rib  is  indicated  when  pressure  symptoms  on  the  sub- 
clavian vessels,  or  on  the  brachial  plexus,  are  sufficiently  severe  to  demand 
relief.  Sometimes  the  rib  itself  is  short  but  is  continued  forward  by  connective 
tissue  bands  which  give  rise  to  sj'mptoms.  The  operation,  which  is  always  diffi- 
cult, may  be  done  through  a  transverse  incision  above  the  clavicle  and  going  from 
the  sternomastoid  to  the  trapezius  muscle.  If  the  rib  is  prominent  and  the . 
protuberance  can  be  palpated  the  incision  is  made  in  such  a  manner  as  will 
give  the  best  exposure.  Dissection  is  carried  carefully  down,  doubly  clamp- 
ing and  trying  the  external  jugular  or  other  veins  until  the  brachial  plexus 
and  the  subclavian  vessels  are  seen.  They  should  be  gently  and  carefully 
retracted.  The  rib  is  separated  from  the  adherent  soft  parts  by  sharp  or 
blunt  dissection,  taking  care  to  avoid  injury  to  the  pleura.  If  possible  the 
periosteum  is  removed  along  with  the  rib  to  prevent  the  re-formation  of  the  rib. 
After  exposing  the  rib  in  front  of  the  subclavian  vessels  and  brachial  plexus  it  is 
divided  .with  bone  forceps.  During  this  division  the  subclavian  vein  is  carefully 
retracted.  It  is  similarly  divided  as  close  to  its  origin  from  the  vertebra  as 
possible  and  the  rib  is  gradually  loosened  and  removed.  The  bleeding  points 
are  carefully  tied  before  closing  the  wound.  In  this  manner  all  of  the  rib  that 
can  have  any  injurious  pressure  effect  is  removed. 

TORTICOLLIS 

Numerous  operations  have  been  devised  for  torticollis,  but  probably  the 
most  satisfactory  is  the  excision  of  a  portion  or  all  of  the  sternomastoid  mus- 
cle, except  in  those  cases  in  which  the  torticollis  is  of  the  spasmodic  variety 
when  excision  of  a  part  of  the  spinal  accessory  nerve  may  be  indicated. 

In  excision  of  the  sternomastoid  muscle,  as  recommended  by  Mikulicz, 
an  incision  is  made  along  the  middle  of  the  lower  portion  of  the  sterno- 
mastoid muscle  extending  upward  from  the  clavicle.  The  sternal  and  clavic- 
ular origins  of  the  sternomastoid  are  exposed  by  dissection  and  the  muscle 
is  separated  from  the  surrounding  tissue.  After  isolating  the  muscle,  it  is 
divided  near  its  origin  and  about  half  way  between  its  origin  and  insertion. 
It  is  important  to  search  for  any  cicatricial  contracting  bands  and  to  divide  or 
excise  them  thoroughly  before  the  wound  is  closed. 

If  the  torticollis  is  spasmodic  this  operation  will  bring  relief  because  it 
destroys  the  function  of  the  muscle,  but  the  lower  end  may  become  attached 
to  tissue  in  the  neighborhood  and  cause  trouble.    Here  it  is  best  to  destroy  the 


THE    NECK  309 

nerve  suiiplylng  the  stenioniastoid  wliieli  is  the  spinal  accessory  nerve.  This 
nerve  may  be  exposed  by  an  incision  which  has  been  described  in  the  operation  for 
anastomosis  of  tlie  facial  and  spinal  accessory  nerves.  The  incision  is  made  about 
three  inches  in  length  from  the  mastoid  process  dovv^nward  along  the  anterior  bor- 
der of  the  sternomastoid.  The  muscle  is  dissected  free  anteriorly,  the  cervical  fas- 
cia incised,  and  the  muscle  retracted  backward.  The  transverse  process  of 
the  atlas,  which  is  covered  by  the  digastric  muscle,  is  recognized  with  the 
finger.  The  spinal  accessory  nerve  passes  betw^een  this  process  and  the 
muscle  and  emerges  at  the  lower  edge  of  the  digastric  to  enter  the  sterno- 
mastoid muscle.  About  half  an  inch  of  the  nerve  can  be  excised  at  this 
point. 

TUBERCULAR  GLANDS  OF  THE  NECK 

Tubercular  glands  of  the  neck  require  different  types  of  operations,  de- 
pending upon  their  location.  The  operation  is  not  so  extensive,  nor  is  the 
dissection  so  radical,  as  in  operations  for  malignant  diseases.  The  glands 
to  be  removed  are  frequently  located  in  the  upper  part  of  the  neck,  but  the 
whole  side  of  the  neck  from  the  mastoid  to  the  clavicle  may  occasionally  be 
involved. 

Dowd,  of  New  York,  recommends  incisions  so  placed  that  they  will  fall 
in  the  natural  creases  of  the  neck,  and  so  smaller  scars  result.  In  the  upper 
portions  of  the  neck  an  incision  parallel  with  and  about  one  or  one  and 
one-half  inches  below  the  border  of  the  lower  jaw,  usually  gives  satisfactory 
exposure.  Care  must  be  taken  in  making  such  an  incision  to  avoid  the 
branches  of  the  facial  nerve  that  go  to  the  muscles  that  depress  the  angle 
of  the  mouth.  From  the  cervicofacial  division  of  the  facial  nerve  comes 
the  mandibular  branch  which  supplies  the  platysma  and  the  depressor  anguli 
oris.  This  courses  along  the  tissues  about  the  lower  border  of  the  jaw  and  if 
protected  by  an  incision  made  well  below  the  lower  border  of  the  jaw  is  not 
disturbed.  For  this  reason  the  incision  should  be  made  as  indicated  and  car- 
ried through  the  platysma  before  the  edges  of  the  wound  are  retracted  or  dis- 
sected up.  If  several  glands  are  involved  together  and  particularly  if  they  are 
matted  to  one  another  it  is  important  to  have  a  satisfactory  exposure.  This 
is  accomplished  by  dissecting  the  lower  portion  of  the  glands,  if  they  are 
located  in  the  inframaxillary  region,  and  first  freeing  the  mass  of  glands  from 
below  and  in  front.  If  the  submaxillary  gland  is  involved,  the  facial  vessels 
are  exposed  after  dissecting  the  mass  of  tissue  backward  and  upward,  and  are 
doubly  clamped  and  divided.  Traction  upon  the  mass  will  then  show  the 
points  of  attachment  which  can  be  divided.  It  must  always  be  borne  in  mind 
that  glands  follow  the  general  course  of  the  veins  and  when  the  glands  are 
abundant  and  adherent  it  is  wise  to  expose  the  large  veins  in  the  neighbor- 
hood, dissect  them  free,  and  then  remove  the  glands  by  dissecting  from  the 
vessels  toward  the  glands  instead  of  in  the  reverse  direction.  If  the  glands 
extend  toward  the  internal  jugular,  this  vessel  is  exposed  by  continuing  the 
dissection  below  until  the  vein  is  reached.    In  closing  the  wound  if  a  consid- 


310  OPERATIVE    SURGERY 

erable  mass  of  glands  lias  been  removed  a  cavity  of  some  size  will  be  left. 
Here  a  small  drainage  tnbe  is  inserted  through  a  short  stab  wound  made, 
preferably,  in  a  crease  of  the  neck  below  the  incision.  The  incision  is  closed 
carefully.  Care  is  taken  to  approximate  the  platysma  in  closing  all  neck 
"wounds,  because  if  this  is  not  done  the  action  of  the  muscle  wull  broaden  the 
scar.  If  the  skin  has  not  been  involved  by  the  tubercular  process  it  is  best  to 
approximate  the  platysma  and  subcuticular  tissue  by  a  continuous  suture  of  fine 
tanned  catgut  before  closing  the  skin.  When  this  is  done  a  continuous  suture 
of  fine  silk  or  fine  silkworm-gut  in  the  skin  leaves  a  very  small  scar,  partic- 
ularly if  the  incision  has  been  made  in  the  crease  of  the  neck.  Fine  silkworm- 
gut  may  be  used  as  a  subcuticular  suture. 

Tubercular  glands  occasionally  are  so  extensive  that  they  require  an 
incision  that  cannot  be  made  to  conform  to  the  creases  of  the  neck.  Here  it 
should  be  so  placed  as  to  render  the  tubercular  glands  easily  accessible.  The 
scar  is  less  conspicuous  if  placed  along  the  posterior  border  of  the  sterno- 
mastoid  muscle,  but  if  the  glands  bulge  forward  it  will  be  necessary  to  make 
the  incision  along  its  anterior  border,  though  this  makes  a  more  prominent 
scar.  The  scar  can  be  greatly  lessened  by  closing  the  wound  carefully,  uniting 
the  platysma  and  subcuticular  tissue  with  catgut  and  the  skin  with  fine  silk 
or  silkworm-gut  and  removing  the  sutures  in  the  skin  as  soon  as  possible. 

MALIGNANT  GROWTHS  OF  THE  NECK 

The  malignant  tumors  of  the  neck  that  may  be  benefited  by  operation  are 
either  primary  tumors  such  as  spring  from  a  branchial  cyst  or  fistula,  or 
metastatic  carcinoma  in  the  lymph  glands  derived  from  a  primary  cancerous 
focus  in  the  head,  face  or  mouth.  Primary  malignant  tumors  of  the  lymph 
glands,  lymphosarcoma,  or  the  tumors  of  the  lymph  glands  in  Hodgkin's  dis- 
ease, are  practically  always  inoperable.  There  is  probably  no  well  authen- 
ticated case  on  record  of  lymphosarcoma  of  the  neck  that  has  been  perma- 
nently cured  by  operation.  Yates  and  Bunting  have  done  very  extensive 
work  with  Hodgkin's  disease  and  feel  that  they  have  cured  some  cases  by 
combination  of  radical  operation,  x-ray,  and  vaccine.  In  their  later  work, 
however,  they  do  not  seem  so  enthusiastic  about  the  ultimate  results  as  they 
were  at  first.  It  is  possible  that  excision  of  the  glands  in  Hodgkin's  disease, 
if  done  radically,  may  delay  the  fatal  issue,  particularly  if  followed  by  in- 
ternal administration  of  arsenic.  Occasionally,  marked  temporary  benefit 
is  obtained,  but  permanent  cure  rarely  if  ever  follows  these  procedures.  The 
application  of  x-ray  or  radium  by  some  one  who  is  skilled  in  such  work  seems 
to  offer  more  hope  in  cases  of  this  type  than  operative  procedures. 

In  metastatic  carcinoma  of  the  lymph  glands  of  the  neck,  however,  opera- 
tion is  often  followed  by  excellent  results  and  radical  surgery  offers  far  better 
prospects  of  cure  than  any  other  method  of  treatment.  The  operation  to  be 
successful  must  be  properly  planned  and  executed.  In  carcinoma  about  the 
mouth  or  face  it  is  advisable  to  do  block  dissection  of  at  least  the  upper  portion 


THE    NECK  311 

of  llie  iiock  even  Uiouyli  there  are  no  glands  tliat  are  palpably  enlarged,  unless 
the  cancer  is  a  basal  cell  cancer.  Here  dissection  of  the  neck  is  unnecessary. 
The  neck  dissection  can  usually  be  done  when  the  growth  in  the  mouth  or  face 
is  removed  and  should  be  the  first  stage  of  the  operation  as  the  chances  of  infec- 
tion are  greater  if  the  procedure  is  reversed. 

To  appreciate  the  lymphatic  drainage  of  the  neck  and  intelligently  to 
])lan  a  radical  operation  in  this  region,  the  anatomy  of  the  lymphatics  and 
the  lymph  glands,  which  has  been  carefully  worked  out  by  Poirier  and  Cuneo, 
must  be  borne  in  mind.  The  lymph  glands  or  nodes  of  the  neck  form,  roughly 
speaking,  a  collar  at  the  junction  of  the  head  and  neck.  On  each  side  of  this 
collar  there  is  a  chain  of  glands  that  follows  along  the  internal  jugular  vein 
and  behind  the  sternomastoid  muscle  down  to  the  upper  portion  of  the  thorax. 
This  upper  circle  of  glands  consists  of  five  groups: 

(1)  The  suboccipital  group  consists  of  from  one  to  three  glands,  which  rests 
on  the  complexus  muscle  just  external  to  the  border  of  the  trapezius.  These 
glands  drain  the  posterior  portion  of  the  scalp  and  their  lymphatics  open  into 
the  upper  glands  of  the  sternomastoid  group. 

(2)  The  mastoid  glands  are  usually  not  more  than  two,  situated  about  the 
insertion  of  the  sternomastoid  muscle.  They  drain  the  temporal  portion  of 
the  scalp,  the  posterior  surface  of  the  ear,  and  the  posterior  surface  of  the 
external  auditory  meatus.  Their  lymph  channels  also  open  into  the  upper 
glands  of  the  sternomastoid  group. 

(3)  The  parotid  glands  constitute  a  group  which  is  rather  numerous. 
They  lie  just  beneath  the  parotid  fascia  or  deeper  in  the  substance  of  the 
parotid  gland.  They  are  not  confined  to  any  one  part  of  the  parotid  gland. 
They  drain  into  the  upper  glands  in  the  sternomastoid  group.  There  are  also 
glands,  sometimes  called  the  subparotid  nodes,  that  lie  behind  the  parotid 
gland  and  drain  the  nasal  fossa  and  the  nasopharynx  and  empty  into  the 
upper  glands  of  the  substernomastoid  group. 

(4)  The  submaxillary  glands,  from  three  to  six  in  number,  ai-e  under  the 
lower  border  of  the  jaw  and  rest  on  the  mylohyoid  muscle  and  on  the  sub- 
maxillar}^  salivary  gland.  Often  a  lymphatic  gland  is  imbedded  in  the  sub- 
maxillary gland.  This  group  is  subdivided  into  anterior  and  posterior  glands. 
The  posterior  glands  are  often  very  large  and  folloAV  the  course  of  the  facial 
vein. 

(5)  The  submental  group  of  lymph  glands  are  three  or  four  in  number 
and  are  deep  in  the  space  between  the  anterior  bellies  of  the  digastric  muscles. 
They  extend  from  the  chin  to  the  hyoid  bone.  They  drain  the  middle  portion 
of  the  lower  lip  and  chin  and  the  corresponding  part  of  the  lower  jaw,  the 
floor  of  the  mouth,  and  the  tip  of  the  tongue.  Lymph  channels  from  these 
glands  open  either  into  the  submaxillary  group  of  glands,  or  go  downward  into 
the  glands  around  the  internal  jugular  vein  about  the  middle  portion  of  the 
neck.  This  group  of  glands  may,  of  course,  drain  into  both  sides  of  the  neck. 
The  tissue  between  the  region  drained  by  the  submental  glands  and  that 
drained  by  the  parotid  glands  is  drained  by  the  submaxillary  group  of  glands. 


312  OPERATIVE    SURGERY 

The  deep  cervical  l^viuphatic  glands  below  the  upper  collar  of  lymph 
glands  form  a  chain  which  reaches  from  the  level  of  the  transverse  process  of 
the  atlas  down  to  the  upper  portion  of  the  thorax.  These  are  numerous  glands 
and  follow  the  general  course  of  the  internal  jugular  vein.  The  upper  part 
of  this  chain  is  beneath  the  sternomastoid  muscle  and  the  lower  part  is  in  the 
subclavian  triangle.  They  are  divided  into  the  substernomastoid  group  and 
the  supraclavicular  group  of  glands. 

The  substernomastoid  group  of  lymph  glands  extends  from  the  level  of 
the  transverse  process  of  the  atlas  to  the  subclavian  vein.  This  group  is  sub- 
divided into  an  external  group,  which  follows  the  posterior  border  of  the 
sternomastoid  muscle,  blending  with  the  glands  in  the  subclavian  triangle; 
and  an  internal  group,  which  is  in  close  contact  with  the  internal  jugular  vein 
and  which  drains  the  glands  of  the  first  five  groups  that  have  been  mentioned. 
One  of  these  glands  which  lies  between  the  posterior  belly  of  the  digastric 
muscle  and  the  internal  jugular  vein  is  very  prominent,  and  has  been  called 
by  Cecil  Leaf  the  " jugulo-cligastric  gland."  This  gland  receives  directly  or 
indirectly  lymphatic  drainage  from  the  tonsils  and  palate,  base  of  the  tongue, 
the  margins  and  some  of  the  central  portion  of  the  tongue. 

The  supraclavicular  group  of  glands,  which  lies  in  the  posterior  triangle 
of  the  neck,  consists  of  numerous  glands  that  are  continuous  above  with  the 
external  group  of  the  deep  cervical  glands.  The  lower  glands  in  this  group 
lie  on  the  omohyoid  muscle  and  along  the  lower  portion  of  the  external  jugular 
vein  and  some  of  the  branches  of  the  cervical  and  brachial  plexus.  They  drain 
the  occipital  region  of  the  scalp  and  posterior  part  of  the  neck,  the  skin  of  the 
pectoral  and  mammary  regions,  portions  of  the  arm  along  the  cephalic  vein, 
and  some  of  the  axillary  lymph  glands.  This  chain  empties  into  the  venous 
circulation  through  the  thoracic  duct,  or  by  separate  lymphatic  trunks  which 
open  into  the  subclavian  vein.  There  is  no  direct  connection  with  the 
mediastinal  glands,  though  of  course,  there  may  be  retrograde  processes 
that  connect  this  group  with  the  mediastinal  glands. 

It  is  readily  seen,  then,  that  an  operation  for  removal  of  metastatic  cancer 
of  the  neck  must  be  undertaken  always  on  the  principle  of  a  block  dissection. 
If  the  involvement  is  slight  removal  of  the  glands  in  a  mass  from  the  upper 
portion  of  the  neck  may  be  all  that  is  necessary,  but  where  it  is  extensive  the 
dissection  must  be  made  from  the  clavicle  to  the  lower  jaw  and  the  mastoid 
process. 

In  operating  for  cancer  the  appearance  of  the  resulting  scar  is  not  im- 
portant but  the  incision  is  made  to  afford  the  greatest  access  to  the  tissues  to 
be  removed  and  to  enable  a  block  dissection  to  be  done.  These  are  the  most 
important  indications,  and  if  rendering  the  scar  inconspicuous  does  not  inter- 
fere with  them,  this  less  important  object  may  also  be  considered. 

In  block  dissection  of  the  upper  neck  if  the  primary  lesion  is  well  on  one 
side  of  the  midline  the  dissection  may  be  limited  to  that  side  of  the  neck  pro- 
vided there  is  no  evidence  of  involvement  of  glands  on  the  other  side  of  the 
neck.    If,  however,  the  lesion  is  in  or  near  the  midline,  dissection  of  both  sub- 


THE    NECK  313 

HKixilhii'v  regions  slioulil  he  done.  If  the  glands  are  extensively  involved  on 
one  side  and  not  on  the  other  it  is  best  to  do  a  hlock  dissection  on  both  sides 
of  the  neck,  because  the  back  pressnre  from  llie  enlarged  glands  has  probably 
forced  cancer  cells  to  the  other  side. 

If  both  sides  of  the  neek  jire  to  be  operated  upon  an  incision  is  made  begin- 
ning over  the  sternomastoid  muscle  just  below  and  posterior  to  the  angle  of  the 
jaw  and  is  carried  forward  about  one  inch  below  the  lower  jaw  to  a  corresponding 
point  on  the  sternomastoid  muscle  on  the  opposite  side.  By  extending  the  neck 
and  elevating  the  chin  the  tissues  are  made  much  more  accessible.  Theoretically, 
the  dissection  should  begin  on  one  side  and  extend  to  the  other,  but  this  is  much 
more  difficult  than  beginning  in  the  midline  under  the  chin  and  dissecting  back- 
ward. If,  however,  the  midline  dissection  is  made  with  an  electric  cautery  and  the 
tissues  in  this  region  are  thoroughly  cauterized,  the  block  dissection  on  either  side 
can  be  safely  started  from  the  midline.  The  skin  dissection  is  carried  below 
and  the  tissues  are  dissected  from  below  and  from  the  midline  backward  and  up- 
ward. Some  fibers  of  the  geniohyoid  and  mylohyoid  muscles  may  be  included 
in  the  mass  of  tissue,  but  the  digastric  can  be  preserved  intact  by  working 
from  before  baclvAvard  and  from  below  upward.  The  line  of  cleavage  of  the 
fascia  and  the  gland  bearing  tissue  is  readily  found.  The  facial  vessels  are 
exposed,  doubly  clamped,  and  divided.  The  mass  is  then  separated  at  its 
upper  margin,  the  surgeon  having  previously  dissected  up  the  skin  and  platysma. 
The  facial  vessels  are  doubh'  clamped  and  divided  at  the  margin  of  the  jaw  bone 
and  the  duct  from  the  submaxillary  gland  is  clamped  before  it  is  divided.  The 
mass  is  separated  from  the  sternomastoid  muscle  and  the  deep  jugular  vein.  If 
the  skin  is  not  involved  along  the  upper  margin  of  the  wound  the  precautions 
about  preventing  injury  to  the  mandibular  branch  of  the  facial  nerve,  which  were 
mentioned  in  connection  with  operations  for  tubercular  glands  in  this  region, 
should  be  borne  in  mind ;  but  if  there  is  a  suspicion  of  involvement  of  the  skin  or 
subcutaneous  tissue  in  this  neighborhood  there  must  be  no  hesitancy  in  sacrificing 
this  nerve. 

During  the  dissection  the  wound  is  flushed  frequently  with  salt  solu- 
tion to  wash  out  cancer  cells  that  may  have  been  freed  during  the  dissec- 
tion. If  there  is  a  point  of  suspicious  cancerous  involvement  which  it  is  not 
thought  wise  to  include  in  the  mass,  it  is  cauterized  with  electric  cautery  pro- 
vided, of  course,  it  is  not  the  wall  of  a  large  vessel.  Tube  drainage  is  provided 
for  by  a  stab  wound  made  posteriorly.  This,  as  has  already  been  explained, 
drains  the  lymph  that  is  poured  out  into  the  wound  following  the  dissection  and 
encourages  reversal  of  the  lymphatic  circulation  to  expel  the  tube.  In  this  way 
cancer  cells  that  might  otherwise  be  absorbed  are  flushed  out  of  the  wound  by  the 
reversed  lymph  supply  and  emptied  through  the  drainage  tube.  The  wound  is 
closed  by  interrupted  sutures  of  silk  or  silkworm-gut  or,  if  the  dissection  permits, 
a  deep  row  of  continuous  catgut  sutures  in  the  platysma,  followed  by  interrupted 
sutures  of  silk  or  fine  silkworm-gut  in  the  skin,  will  make  a  nicer  scar. 

If  the  lymph  glands  are  involved  below  the  inframaxillary  region  or  if 
they  are  markedly  enlarged  in  the  inframaxillary  region,  it  is  best  to  make  a 


314  OPERATIVE   SURGERY 

block  dissection  of  the  entire  side  of  tlie  neck.  This  operation  was  first  de- 
scribed in  a  systematic  manner  by  Crile.  Crile's  upper  incision  goes  from 
behind  and  below  the  mastoid  process  forward  beneath  the  jaw,  terminating 
in  the  midline  just  beneath  the  chin.  Another  incision  begins  about  the  junc- 
tion of  the  posterior  and  middle  thirds  of  the  first  incision  and  goes  down 
over  the  middle  of  the  sternomastoid  muscle  to  the  lower  border  of  the  clavicle. 
If  necessary  a  horizontal  incision  can  be  made  either  forward  or  backward 
from  the  lower  end  of  the  sternomastoid  incision.  The  skin  and  platysma  are 
widely  dissected  along  the  margins  of  the  wound.  The  sternomastoid  muscle 
is  freed  from  the  carotid  artery  and  the  internal  jugular  vein  and  is  doubly 
clamped  and  divided.  The  sheath  which  surrounds  the  carotid  artery,  jugu- 
lar vein  and  the  vagus  nerve  is  opened  and  the  vein  is  freely  exposed.  Care  is 
taken  to  identify  the  carotid  artery  and  the  vagus  nerve.  The  jugular  vein  is 
doubly  ligated  in  its  proximal  portion  just  above  the  clavicle.  Ligatures  are 
placed  about  one-c[uarter  of  an  inch  apart  and  are  of  catgut.  Another  ligature 
or  clamp  is  placed  at  a  safe  distance  about  the  second  ligature  and  the  jugular 
vein  is  divided  just  below  the  upper  ligature  or  clamp.  The  tissues  of  the  neck, 
including  the  sternomastoid,  the  jugular  vein,  fat,  fascia  and  glands  in  the 
neighborhood  are  dissected  up  in  one  mass. 

Crile  advises  placing  a  soft  clamp  on  the  common  carotid  artery  for 
temporary  hemostasis  but  this  seems  unnecessary.  The  bleeding  is  read- 
ily controlled  by  hemostats,  and  when  the  bifurcation  of  the  common  car- 
otid is  reached  the  external  carotid  is  doubly  ligated  a  short  distance 
above  the  bifurcation.  As  the  dissection  continues  leaving  the  common 
and  internal  carotid  arteries  and  vagus  and  phrenic  nerves,  the  facial,  lin- 
gual and  occipital  branches  of  the  external  carotid  are  also  tied.  The  submax- 
illary space  is  dissected  from  in  front  and  below^  upward  and  backward,  as  has  al- 
ready been  described,  and  is  separated  from  its  upper  connection  leaving  this  mass 
of  tissue  attached  posteriori}'  to  the  main  mass  around  the  sternomastoid  mus- 
cle and  the  internal  jugular  vein.  The  sternomastoid  muscle  is  severed  from 
its  insertion  just  below  the  mastoid  process,  and  the  fascia  and  tissue  in  its 
neighborhood  are  carefully  dissected  forward  until  the  upper  portion  of  the 
internal  jugular  vein  is  exposed.  This  is  recognized  because  it  is  strutted  with 
blood,  being  clamped  below^  The  vein  is  ligated  as  high  up  as  possible  just 
as  it  w^as  ligated  above  the  clavicle,  passing  two  catgut  ligatures  about  one- 
quarter  of  an  inch  from  each  other,  clamping  and  dividing  the  vein  below  the 
second  ligature.  The  internal  carotid  and  the  vagus  nerve  are  identified  during 
this  ligation.  The  attachment  of  the  mass  of  tissue  which  is  just  below  the 
parotid  gland  and  the  posterior  angle  of  the  jaw  is  cut  aAvay  Avith  a  sharp 
knife  (Fig.  338).-  Often  a  portion  of  the  parotid  gland  is  wounded  and  the 
bleeding  from  this  region  may  be  annoying.  It  is  readily  controlled,  however, 
by  whipping  it  over  with  sutures  of  catgut.  The  Avound  is  frequently  flushed 
out  Avith  salt  solution  during  the  operation.  Suspicious  points  may  be  touched 
Avith  the  electric  cautery,  particularly  at  the  root  of  the  neck,  though  care  must 
be  taken  in  this  region  not  to  injure  the  pleura  or  the  thoracic  duct.    A  drain- 


THE    NECK 


315 


age  tube  is  plaeetl  liiroimh  a  si  ah  woiiiul  in  the  skin  jxjslerior  to  tlie  wound. 
The  M'ounil  is  closed  as  in  the  block  dissection  in  the  upper  part  of  tiie  neck. 
The  lymphatic  drainage  from  such  a  wound  is  very  extensive  for  the  first 
twenty-four  hours  and  it  may  give  the  impression  of  a  hemorrhage.  If  proper 
care  is  taken  to  ligate  or  suture  all  bleeding  points  there  should  be  no  danger 
of  secondary  hemorrhage,  unless  there  is  infection.  The  large  lymphatic 
trunks  that  have  been  cut  will  naturally  pour  out  an  abundant  supply  of 
lymph. 


Fig.   338. — A  completed  block   dissection   of  one   side   of  the  neck. 


If  the  operation  just  described  is  undertaken  in  connection  with  resection 
of  a  portion  of  the  jaw  for  cancer,  the  cavity  of  the  mouth  Avill  necessarily 
communicate  with  the  wound  and  infection  will  probably  occur.  Here  sec- 
ondary hemorrhage  may  be  feared.  As  the  common  carotid  is  left  by  the  dis- 
section just  beneath  the  skin,  it  can  be  readily  compressed  or  by  removing 
a  few  sutures  or  incising  the  skin  it  can  be  clamped.  Such  an  accident,  how- 
ever, is  always  serious,  though  the  great  value  of  the  block  dissection  in  can- 
cer makes  it  seem  wiser  to  risk  such  a  danger  in  the  hope  of  a  cure  of  the  cancer 
than  to  undertake  the  operation  in  two  stages  when  there  will  necessarily  be 


316  OPERATIVE   SURGERY 

a  break  in  the  block  dissection.  Even  when  the  tissues  are  cauterized  if 
there  is  an  interval  of  several  days  between  the  mouth  operation  and  the  neck 
operation,  there  is  daiiger  of  the  cauterized  tissue  being  absorbed  and  cancer 
cells  being-  transported  from  the  primary  focus  into  the  extensive  wound  made 
by  the  operation  in  the  neck.  Cauterization  of  tissue  Avill  seal  the  lymphatics, 
destroy  cancerous  tissue  in  the  neighl)orhocd,  and  render  the  tissues  temporar- 
ily safe  from  invasion  of  cancer  but  this  immunity  passes  off  in  a  few  days 
when  the  tissue  that  has  been  destroyed  by  the  cauterization  has  been  ab- 
sorbed and  the  Ij^mphatics  have  again  opened  up. 

THE  LARYNX  AND  TRACHEA 

Operations  upon  the  larynx  are  usually  for  malignant  disease.  AVhen 
the  cancer  is  confined  to  one  of  the  vocal  cords,  or  if  only  a  small  portion  of 
the  larynx  is  involved,  or  if  the  growth  is  benign,  a  satisfactory  operation  is 
laryngotomy.  An  incision  is  made  in  the  midline,  extending  from  the  hyoid 
bone  to  the  first  ring  of  the  trachea.  The  cricothyroid  membrane  is  divided 
and  the  thyroid  cartilage  is  carefully  split  in  the  midline.  This  is  done  with 
strong  scissors  or  a  thin-bladed  bone  forceps.  "When  the  cartilage  is  very  hard 
a  fine  saw  may  be  used.  The  lateral  halves  of  the  thyroid  cartilage  are  re- 
tracted with  sharp  hooks  and  the  interior  of  the  larynx  is  sprayed  or  gently 
mopped  out  with  a  one  per  cent  solution  of  cocaine.  Attention  is  given  to 
hemostasis  and  no  blood  is  allowed  to  flow  into  the  trachea.  If  the  growth  is 
malignant  it  is  best  to  remove  it  with  the  electric  cautery. 

Many  operators  perform  the  first  step  of  laryngotomy  or  laryngeal  fis- 
sure by  making  a  low  tracheotomy.  If  the  operation  in  the  larynx  is  to  be 
extensive  this  is  a  wise  procedure,  but  if  not,  the  thyroid  cartilage  can  be 
united  by  two  sutures  of  catgut  and  the  wound  closed.  A  small  tube  or 
piece  of  gauze  is  placed  in  the  lower  angle  of  the  wound  leading  down 
to  the  thyroid. cartilage  in  order  to  prevent  emphysema  which  may  occur  if 
there  is  a  spell  of  coughing  and  the  skin  is  closed  too  tightly. 

Tracheotomy  may  be  the  first  procedure  in  a  laryngeal  operation.  "When 
a  tracheotomy  is  an  emergency  operation  and  Avhen  there  is  danger  of  asphyxia 
it  can  be  quickly  done  by  a  stab  of  a  knife.  Usually  in  such  emergencies  an 
incision  in  the  cricothyroid  membrane  with  the  insertion  of  a  forceps,  which 
is  spread  open,  is  all  that  is  necessary.  Before  attempting  tracheotomy 
in  emergency  cases  the  patient  is  given,  if  possible,  a  dose  of  morphine  and 
atropin  hypoderniically.  This  not  only  lessens  the  excitement  of  the  patient, 
but  the  atropin  serves  to  lower  the  sensibility  of  the  terminals  of  the  vagus 
nerve  in  the  hearrt  and  so  diminishes  the  danger  of  reflex  inhibition  of  the  heart. 
It  also  has  a  very  beneficial  effect  in  decreasing  the  amount  of  mucus.  In 
emergency  cases  the  operation  is  done  under  local  anesthesia  and  in  grave 
emergencies  a  stab  wound  is  quickly  made  in  the  midline  of  the  trachea. 

In  cases  that  are  not  urgent  emergencies  the  trachea  may  be  opened  either 
in  its  upper  portion  where  it  is  more  accessible  or  loAver  where  the  trachea 


THE   NECK  317 

is  deoper.  A  transverse  iiieisioii  in  Ihc  skin  makes  the  best  scar,  but  where 
traelieotoiny  is  indicated  the  scar  is  often  a  minor  consideration.  The  incision, 
whether  transverse  or  vertical,  is  made,  and  the  isthmus  of  the  thyroid,  if  it 
interferes  with  the  dissection,  is  divided  down  to  the  trachea.  The  raw  sur- 
faces of  the  thyroid  gland  are  whipped  over  Avith  sutures  of  catgut  to  control 
bleeding  and  retracted  to  each  side  out  of  the  way.  After  the  trachea  is  fully  ex- 
posed the  tissues  between  the  rings  are  carefully  infiltrated  with  novocain 
solution  to  which  has  been  added  a  small  amount  of  epinephrin.  It  is  highly 
important  to  prevent  blood  gaining  access  to  the  trachea  and  infiltration,  par- 
ticularly when  epinephrin  is  added,  lessens  bleeding.  The  trachea  is  divided 
between  the  rings  with  a  transverse  incision.  If  more  room  is  needed  the  rings 
are  cut  across,  but  usually  this  is  not  necessary.  If,  however,  a  tracheotomy 
tube  is  to  be  worn  for  a  considerable  length  of  time  it  may  be  necessary  to 
divide  one  or  more  of  the  tracheal  rings.  As  soon  as  the  trachea  is  opened 
the  mucosa  is  anesthetized  by  spraying  with  a  small  amount  of  one  per  cent 
cocaine  solution  or  two  per  cent  novocain  solution.  This  is  applied  very  gently 
and  no  further  procedure  is  taken  until  a  few  minutes  have  elapsed  for  the 
anesthetization  of  the  mucosa.  A  good  way  to  anesthetize  the  tracheal  mucosa 
is  to  inject  with  a  hypodermic  syringe  a  few  drops  of  a  two  per  cent  cocaine 
solution  into  the  lumen  of  the  trachea  between  its  rings.  This  is  done  after 
exposing  the  trachea  and  a  few  minutes  before  opening  it.  After  being  incised 
the  trachea  is  held  open  by  small  sharp  retractors  and  a  tube  is  gently  inserted. 
In  an  emergency  a  large  drainage  tube  can  be  used,  the  outer  end  being  split  in 
half  and  these  halves  immobilized  by  being  tied  to  tapes  which  meet  around  the 
neck.  Or  a  piece  of  wire  or  a  hair-pin  can  be  bent  in  such  a  shape  as  to  keep 
the  trachea  open. 

The  air  of  the  patient's  room  must  be  warm  and  moist.  Loose  gauze 
that  is  kept  constantly  moist  is  placed  over  the  tracheotomy  tube.  If  a  regular 
tracheotomy  tube  is  used  it  Avill  be  necessary  to  clean  the  inner  tube  frequently 
as  soon  as  it  is  apparent  from  the  breathing  that  an  excess  of  mucus  has 
accumulated.  The  dressings  over  the  wound  and  tracheotomy  tube  are  fre- 
quently changed. 

When  it  is  necessary  to  close  a  tracheotomy  wound  the  scar  is  dissected 
from  the  normal  tissue,  the  wall  of  the  trachea  infiltrated  with  novocain  and 
epinephrin,  and  freshened.  On  release  of  the  scar  the  trachea  usually  falls 
together  and  if  the  skin  and  superficial  tissue  have  been  thoroughly  mobilized 
it  is  usually  not  necessary  to  put  sutures  in  the  trachea. 

When  there  is  a  stricture  of  the  trachea,  which  may  follow  the  long 
wearing  of  a  tracheotomy  tube  or  may  result  from  ulceration,  the  problem  is 
ciuite  difficult.  The  most  satisfactory  operation,  in  the  opinion  of  Crile,  is 
resection  of  the  strictured  area.  The  trachea  is  then  united  by  mattress 
stitches  of  silver  Avire  Avhich  include  a  ring  of  the  trachea  above  the  stenosis 
and  one  below  it.  Three  sutures  of  rather  heavy  silver  wire  are  placed,  one 
on  each  side  of  the  esophagus  and  one  in  front.  Crile  leaves  the  front  end 
long  so  it  emerges  from  the  Avound  and  tAvists  the  sutures  until  apposition  of 


318 


OPERATIVE    SURGERY 


the  tracheal  wound  is  satisfactory.     This  presupposes  that  the  rings  of  the 
trachea  are  normal  and  are  not  softened  by  disease  or  inflammation. 

In  laryngectomy  it  is  highly  important  to  select  an  appropriate  anesthetic. 
A.  D.  Bevan  prefers  to  do  a  laryngectomy  under  local  anesthesia.  The  opera- 
tion, which  is  often  rather  long  and  tedious,  is  quite  trying  on  the  patient  if 
done  under  a  local  anesthetic,  though  the  danger  may  be  thereby  decreased. 
Bevan  does  a  laryngectomy  in  one  stage  and  apparently  feels  that  the  pre- 
liminary procedures,  as  tracheotomy  and  partial  dissection  of  the  larynx,  are  not 
necessary.     The  rectal  anesthesia  method  of  Gwathmey  seems  ideal  for  lar- 


Fig.    339. — Lines   of   incision   for   laryngectomy. 

yngectomy,  but  if  for  any  reason  this  is  not  preferred,  a  large,  snugly  fitting 
rubber  tube  that  is  well  lubricated  is  inserted  into  the  trachea  and  the  anes- 
thetic administered  through  this  tube,  which  is  connected  with  a  funnel  over 
which  is  stretched  a  few  layers  of  gauze,  the  ether  being  dropped  on  the 
gauze.  Care  should  be  taken  to  hold  the  tube  and  the  funnel  in  such  a  man- 
ner that  no  liquid  ether  can  gain  access  to  the  trachea.  This  method  of  giving 
the  anesthetic  should  not  be  employed  unless  there  is  some  positive  contraindica- 
tion for  the  use  of  the  Gwathmey  rectal  anesthesia,  or  local  anesthesia. 

A  vertical  incision  is  made  along  the  median  line  from  a  point  just  above 
the  hyoid  bone  to  the  border  of  the  sternum.     A  transverse  incision  is  made 


THE    NECK 


319 


just  al)()ve  tlu>  liyo'ul  bone  nuikin^ii'  witli  the  iiicdiaii  cut  a  T-shajx'd  incision 
(Fig.  339).  If  necessary  a  similar  transverse  incision  can  he  made  at  the 
h)wer  end  of  the  vertical  one.  If  a  tracheotomy  has  not  been  previously 
done  tlie  same  steps  of  dividing  the  isthmus  of  the  thyroid  gland  and  control- 
ling the  bleeding  surface  by  whipping  it  over  with  catgut  as  has  been  de- 
scribed under  the  teclmic  of  tracheotomy  are  taken.  The  tissues  are  dissected 
freely  from  each  side  of  the  larynx,  separating  and  dividing  the  sternohyoid 
and  sternothyroid  muscles  on  each  side,  as  well  as  the  thyrohyoid  at  its  in- 


Fig.    3t0. — The    larynx    has    been    exposed    and    partly   mobilized.      In    the   next    step    of    the    operation    the 

trachea  is  severed  from  the  larynx. 


sertion  into  the  thyroid  cartilage.  The  larynx  is  completely  freed  as  far  as 
possible  on  each  side  (Fig.  340)  and  then  after  infiltrating  the  space  between 
the  upper  ring  of  the  trachea  and  the  cricoid  cartilage  in  order  to  lessen  bleed- 
ing, a  few  drops  of  a  two  per  cent  solution  of  cocaine  are  injected  into  the 
lumen  of  the  trachea  with  a  hypodermic  syringe.  After  a  few  minutes  the 
mucosa  of  the  trachea  and  larynx  is  anesthetized.  Then  the  trachea  is  cut 
across.  The  dissection  is  continued  and  the  larynx  is  separated  from  the  esoph- 
agus behind.  If  a  tracheotomy  tube  is  not  used,  the  trachea,  after  being 
divided,  is  separated  from  the  esophagus  for  a  distance  of  an  inch  or  more, 
and  brought  forward  and  sutured  to  the  skin.     Great  care  is  taken  to  see 


320 


OPERATIVE    SURGERY 


that  there  is  no  oozing  or  trickling  of  blood  into  the  traeliea.  ( Jan/e  is  lightly 
packed  just  behind  its  posterior  cut  margin  to  control  l)leeding.  Bevan 
thinks  that  patients  do  much  better  without  a  tracheotomy  tube.  After 
disposing  of  the  stump  of  the  trachea  the  larynx  is  seized  with  forceps 
and  pulled  upward  toward  the  chin  and  the  dissection  from  the  esoph- 
agus is  continued  to  the  upper  extremity  of  the  larynx  behind.  The  esophagus 
is  incised  and  the  larynx  is  cut  away  at  its  upper  portion,  dividing  ligaments 
and  muscles  that  are  attached  laterally  to  the  larynx,  and  finally,  the  thyro- 
hvoid  membrane.     The  entire  larynx,  usually  with  the  epiglottis,  is  removed 


Fig.    341. — The    trachea   has   been    divided    and   brought   to    the    skin.      The    larynx    is    being    dissected    out 

from  below  upward. 

in  one  mass  (Fig.  341).  The  wound  in  the  esophagus  and  pharynx  is  closed 
by  continuous  silk  or  linen  sutures.  The  sutures  are  applied  as  snugly  as 
possible  in  an  effort  to  prevent  leakage,  but  if  made  too  tight  or  too  numerous 
necrosis  will  occur  and  the  wound  will  break  down.  Wherever  possible  the 
sutured  opening  in  the  pharynx  is  reinforced  by  drawing  soft  tissues  in  its 
neighborhood  over  it.  The  skin  wound  is  closed,  leaving  iodoform  gauze  drain- 
age at  the  lower  portion  of  the  wound  just  above  the  stump  of  the  trachea  and 
at  each  end  of  the  transverse  incision  along  the  hyoid  bone  (Fig.  342).  The 
patient  is  put  to  bed  in  the  Trendelenburg  position  if  the  operation  has  been 


THE    NKCK        ..  321 

(lone  uiulri-  a  liciicral  aiirsllu'tic,  l)iit  as  soon  as  lie  rocovei's  tlio  head  of  llic 
bed  is  elevated  or  he  is  placed  in  a  seiui-sillinii'  ])osilioii  in  hed.  AVater  is  snp- 
plied  by  rectal  enemas,  or  if  necessary  by  hypodernioclysis.  After  two  days, 
feedinii'  is  undertaken  by  introducing  a  large  soft  rubber  catheter  through  the 
mouth  into  the  esophagus  well  below  the  level  of  the  larynx.  Through  this 
catheter,  which  is  attached  to  a  funnel,  liquid  nourishment  can  be  gradually 


Fig.   342. — The   laryngectomy   completed. 

poured.     In   this   way   leakage   of   food   through   the   pharyngeal   wound   is 
avoided.     This  method  of  feeding  can  be  kept  up  for  about  two  weeks. 

PHARYNX  AND  ESOPHAGUS 

Occasionally  it  is  necessary  to  have  access  to  the  pharynx  from  the  neck. 
This  is  obtained  by  an  incision  above  the  hyoid  bone  and  parallel  to  it.  The 
submaxillary  gland  is  retracted  and  the  digastric  muscle  is  recognized  and 
preserved.  Other  muscles  of  the  neck,  that  is,  the  mylohyoid,  geniohyoid,  and 
the  hyoglossus  are  divided  transversely.  The  posterior  part  of  the  tongue  is 
pulled  into  the  wound  with  sharp  retractors.  The  pharynx  may  also  be 
entered  by  an  incision  below  the  hyoid  bone  and  parallel  to  it.  If  entrance  to 
the  larynx  is  desired  a  short  incision  of  two  inches  is  sufficient  but  if  the 
pharynx  farther  back  is  to  be  reached  the  incision  should  be  much  longer. 
The  thyrohyoid  membrane  is  divided  along  the  posterior  portion  of  the  hyoid 
bone,  but  enough  of  this  membrane  is  left  attached  to  the  bone  to  hold  the 
sutures.  The  mucosa  is  divided,  taking  care  to  avoid  injury  to  the  epiglottis. 
Sutures  in  the  mucosa  along  the  edge  of  the  wound  act  as  retractors.  The 
epiglottis  is  pulled  into  the  wound  and  a  tractor  suture  is  inserted  into  it. 
The  wound  is  closed  by  uniting  the  thyrohyoid  membrane  and  the  muscles  in 
separate  layers  with  catgut.    It  is  best  to  insert  a  small  drain. 

To  remove  a  tumor  or  a  foreign  body  that  has  lodged  in  the  esophagus 
an  incision  is  made  on  the  left  side  beginning  at  the  upper  level  of  the  larynx 
and  going  down  along  the  anterior  border  of  the  sternomastoid  muscle  for 
three  or  four  inches.  The  incision  is  deepened  and  the  omohyoid  is  divided 
or  retracted.  The  thyroid  gland  and  the  trachea  are  retracted  toward  the 
midline,   and   the   common   carotid,   internal   jugular   vein   and  vagus   nerve 


322  OPERATIVE    SURGERY 

are  retracted  outward  in  their  sheath.  The  esophagus  is  exposed  and  if  a 
foreign  body  is  present  and  can  be  felt  an  incision  is  made  in  the  axis  of  the 
esophagus  down  to  tlie  foreign  bodj^  Before  incising  the  esophagus  it  is  best 
to  fix  its  wall  by  tenacula  forceps  or  by  insertion  of  sutures  that  will  act  as 
tractors.  If  the  incision  is  made  for  a  tumor  and  the  esophagus  is  not  readily 
exposed  an  esophageal  bougie  is  inserted  through  the  mouth  to  make  it 
prominent.  To  avoid  the  recurrent  laryngeal  nerve,  the  incision  is  made 
in  the  side  of  the  esophagus  and  not  in  front  of  it.  The  wound  is  closed 
by  interrupted  sutures  of  fine  catgut  in  the  esophagus,  which  should  not 
be  tied  too  tightly.  The  rest  of  the  wound  is  partially  closed,  leaving 
abundant  drainage  down  to  the  esophageal  wound  in  order  to  provide  drain- 
age if  the  Avound  in  the  esophagus  leaks,  which  it  frequently  does,  and  also 
to  guard  against  mediastinitis,  Avhich  is  a  considerable  danger  in  these  cases. 

An  esophageal  diverticulum  may  occur  from  pressure  Avithin  the  esoph- 
agus or  from  traction  without  the  esophagus,  as  from  a  contracting  adhesion 
that  involves  its  Avails.  The  latter  form  of  diA^erticulum  is  rare,  but  oc- 
casionally occurs  in  that  portion  of  the  esophagus  within  the  chest.  The 
most  common  site  of  esophageal  diverticulum  is  at  the  lateral  and  poste- 
rior portion  of  the  junction  of  the  esophagus  and  pharynx.  Here  there  seems 
to  be  a  Aveak  spot  as  there  is  a  Aveak  spot  at  the  internal  opening  of  the  in- 
guinal canal  where  hernia  often  occurs.  Pressure  from  swallowing  makes  a  pouch 
at  this  weak  spot  at  the  beginning  of  the  esophagus  and  the  pouch  may  con- 
tinue to  enlarge  until  it  attains  considerable  dimensions.  When  A^ery  large 
a  diverticulum  may  interfere  seriously  Avith  the  passage  of  food.  In  operat- 
ing, an  incision  is  made  as  for  esophagotomy,  Avhich  has  just  been  described. 
The  tissues  are  retracted  and  usually  the  diA^erticulum  is  readily  found.  It 
is  dissected  free  bluntly  and  brought  into  the  wound.  The  safest  plan  is  to 
pack  the  Avound  AA'ith  gauze  for  about  a  week  until  granulations  in  the 
tissues  have  established  a  defense  against  infection  and  the  occurrence  of 
mediastinitis.  If  the  diverticulum  is  a  large  one  it  is  brought  out  of  the  skin 
Avouncl  and  left  in  this  position  surrounded  by  gauze.  A  small  cliA^erticulum 
can  sometimes  be  pulled  up  so  that  it  stands  at  a  right  angle  from  the  esopha- 
gus. A  small  amount  of  packing  is  placed  beloAV  it  and  most  of  the  skin  AVOund 
is  closed.  At  a  second  operation,  a  week  or  ten  days  later,  care  must  be  taken 
not  to  break  through  the  barrier  of  granulations  and  coagulated  lymph,  par- 
ticularly in  the  loAver  portion  of  the  wound.  The  neck  of  the  sac  is  cut  aAvay, 
the  margins  of  the  Avound  in  the  esophagus  being  clamped  or  sutured  as  the 
incision  is  made  so  as  to  prevent  too  great  retraction  of  the  esophagus.  Care 
must  be  taken  so  to  cut  off  the  diverticulum  as  to  leaA^e  no  pouch  AA'hen  the 
stump  is  sutured.  If,  hoAvcA^er,  too  much  of  the  esophagus  is  removed  a 
stricture  may  result.  The  stump  is  sutured  preferably  Avith  catgut,  and  if  pos- 
sible this  'layer  of  sutures  is  iuA^erted  by  a  second  layer.  Iodoform  gauze 
drainage  is  carried  doAvn  to  the  Avound  in  the  esophagus  and  the  skin  Avound 
is  partially  closed. 

When  the  diA''erticulum  is  small  it  may  sometimes  be  iuA^erted  into  the 


THE    NECK 


323 


esophagus  by  a  series  ol'  i)ui'sesti'niG,'  siilures,  llie  lii'st  sutures  being  in- 
serted near  the  tip  of  tlu'  divertieulum,  inverting  the  tip,  and  the  second 
farther  down,  inverting  still  more  of  the  diverticulum,  and  so  on  until  the  last 
pursestring  suture  merely  closes  the  dimple  in  the  esophageal  wall.  This 
is  the  method  practiced  by  A.  D.  Bevan,  and  if  the  diverticulum  is  small 
and  thin  and  can  be  readily  inverted  the  operation  is  done  safely  at  one 
sitting,  as  the  esophagus  is  not  opened.  The  inverted  diverticulum  is  sup- 
posed to  atrophy  or  to  slough  off.  In  a  large  diverticulum  or  in  one  with  thick 
walls  this  operation  cannot  readily  be  done  and  the  two-stage  operation  with 
excision  of  the  diverticulum,  which  is  the  method  described  by  Judd  and  usu- 
ally followed  at  the  Mayo  clinic,  is  preferable. 

After  any  operation  upon  the  esophagus  the  patient  should  be  nourished 
as  recommended  after  excision  of  the  larynx.  He  is  given  enemas  for  the 
first  few  days  and  afterwards  nourished  through  a  small  stomach  tube  passed 
through  the  mouth.  Where  the  esophagus  has  not  been  opened,  however,  as 
when  a  diverticulum  is  inverted,  there  is  no  occasion  for  the  use  of  the  stomach 
tube  though  the  swallowing  should  be  restricted  as  much  as  possible  for  the 
first  week  by  giving  liquids  by  enemas  and  by  administering  only  liquid 
nourishment  by  mouth. 

In  an  esophageal  stricture  a  pouch  often  forms  above  the  stricture  and 
renders  the  passage  of  a  sound  or  bougie  very  difficult.  When  the  stricture 
cannot  be  entered  from  above.  Abbe  has  practiced  gastrotomy  and  the  inser- 
tion of  a  small  whalebone  bougie  from  below.  This  passes  into  the  mouth  and 
two  stout  threads  are  tied  to  the  end  of  the  bougie  and  drawn  through  from 
the  mouth  into  the  stomach.  The  threads  act  as  a  guide  to  an  esophageal 
bougie,  which  is  tunnelled  and  threaded  over  the  end  of  the  thread  that  pro- 
trudes from  the  mouth.  After  the  esophageal  bougie  has  engaged  the  stric- 
ture the  second  string  is  pulled  upon  with  a  see-saw  motion  so  as  to  cut  the 
stricture.  Ochsner  advises  drawing  a  rubber  tube  under  tension  through  the 
stricture  so  that  when  the  tension  is  relaxed  the  tube  expands  and  dilates  the 
stricture.  The  tube  is  left  in  position  for  several  days  when  a  larger  one  is 
inserted,  and  so  on  until  the  stricture  has  been  overcome.  The  patient,  of 
course,  is  fed  in  the  meantime  through  the  gastrotomy  wound.  Occasionally 
a  fine  silk  thread  can  be  passed  through  a  stricture  by  floating  it  in  water  and 
taking  the  water  through  a  tube.  After  several  days  the  thread  may  pass 
through  the  stomach  and  into  the  duodenum  in  such  a  way  as  to  fix  the  end  of 
it  and  the  thread  can  be  made  taut  and  serve  for  the  introduction  of  a  bougie. 
S.  J.  Mixter,  of  Boston,  has  practiced  this  method  with  much  success. 

THE  CAROTID  GLAND 

The  carotid  gland  varies  considerably  in  size  and  is  found  near  the  bifur- 
cation of  the  common  carotid  artery.  It  is  closely  attached  to  the  internal 
carotid  and  contains  groups  of  epithelial  cells  which  have  a  function  through 
internal  secretion  probably  connected  with  the  function  of  the  adrenal  gland  and 


324  OPERATIVE    SURGERY 

the  sympathetic  nervous  system.  Tumors  of  this  gland  have  been  found.  Some- 
times the  tumors  are  quite  malignant,  l)ut  usually  tliey  grow  slowly  and  are 
mildly  malignant  if  not  actually  benign.  The  treatment  of  such  tumors  is  very 
difficult  to  determine.  If  operation  is  deferred  until  the  growth  is  large  it 
will  almost  invariably  be  necessary  to  resect  a  portion  of  the  carotid  arteries 
involved  in  the  growth.  When  the  tumor  is  small  the  operation  is  less  difficult, 
but  even  then  the  intimate  association  of  the  carotid  gland  with  the  carotid 
vessels  makes  it  frequently  impossible  to  remove  the  gland  without  serious  in- 
jury to  the  walls  of  the  carotids.  Aside  from  hemorrhage  the  chief  danger  of 
the  operation  is  in  cutting  off  the  blood  supply  to  the  brain  by  the  ligation  of 
the  common  and  internal  carotid  arteries.  This  serious  objection  to  the 
operation  may  be  partially  overcome  by  the  employment  of  malleable  bands 
that  have  been  described  in  the  treatment  of  carotid  aneurisms,  or  by  the  use 
of  Crile's  clamp  which  can  be  nicely  adjusted  by  a  screw.  By  either  of  these 
devices  the  circulation  through  the  internal  carotid  is  gradually  cut  off  until 
it  is  found  that  the  common  carotid  can  be  completely  occluded  Avith  safety. 
This  may  be  weeks,  but  then  it  will  be  reasonably  safe  to  tie  the  common 
carotid  below  and  the  external  and  internal  carotids  above  and  excise  the 
growth.  If  it  is  found  that  the  circulation  to  the  brain  cannot  be  sufficiently 
developed  by  this  method  after  it  has  been  given  a  satisfactory  trial,  and  if 
the  tumor  appears  to  be  malignant  and  endangering  life,  an  attempt  might 
be  made  to  resect  the  carotid  arteries  and  suture  between  the  stumps  of  the 
common  and  internal  carotid  arteries  a  segment  of  the  saphenous  vein  which 
is  taken  from  the  same  joatient.  Indications  for  this  operation  will  be  very 
unusual,  but  such  a  condition  may  conceivably  occur  and  if  the  surgeon  can 
suture  blood  vessels  satisfactorily  the  operation  may  give  a  chance  in  an  other- 
wise hopeless  situation.  The  suturing  should  be  done  as  described  in  the  chapter 
on  Blood  Vessel  Suturing. 

DIFFUSE  LIPOMA  OF  THE  NECK 

Occasionally  a  diffuse  lipoma  of  the  neck  is  so  large  as  to  indicate  oper- 
ation. Often  this  is  accompanied  by  S3anmetrical  lipomas  elsewhere  and  by 
nervous  disturbances  that  would  contraindicate  operation  upon  the  lipoma 
of  the  neck.  If,  however,  the  diffuse  lipoma  of  the  neck  is  the  chief  or  only 
growth  and  there  is  no  contraindication,  the  tumor  may  be  removed  through 
a  long  transverse  incision  over  the  most  prominent  portion  of  the  growth. 
The  dissection  required  is  very  extensive  and  the  vessels  are  often  greatly 
displaced.  The.  dissection  begins  at  one  of  the  tAvo  extremities  of  the  in- 
cision over  the  edges  of  the  trapezius  muscle,  and  extends  forward  after 
freeing  the  tumor  above  and  below  as  much  as  possible.  Care  is  taken  to 
identify  the  large  veins  at  the  root  of  the  neck  and  to  guard  against  the  en- 
trance of  air  into  the  veins  (Figs.  343  and  344).  For  this  reason  the  vessels 
in  the  lower  portion  of  the  growth  are  identified  and  clamped  before  dissecting 
those  at  the  upper  portion.     The  external  jugular  veins  are  usually  buried  in 


THE    NECK 


325 


the  mass  of  fat  wliieli  extends  into  the  cre^'ices  between  the  muscle  plains  and 
around  the  deep  vessels  of  the  neck.  It  is  often  impossible  to  remove  all  of 
a  large  diffuse  lipoma  in  one  mass,  but  if  there  is  no  distinct  capsule  it  can  be 
removed  in  sections  if  this  renders  the  operation  easier.    The  wound  is  washed 


1 

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jitt^                   Jt 

V 

t7 

r 

i 

1 

K^--_ 

I 

343. — Photograph     of    a    patient    with    large 
diffuse   lipoma   of    the   neck. 


Fig.  344. — Photograph  of  patient  shown  _  in 
preceding  illustranon  a  few  weeks  after  operation 
for    removal    of    diffuse    lipoma. 


out  with  salt  solution  and  dried  Avitli  gauze  to  remove  the  fat  that  may  be 
licjuefied  and  scjueezed  into  the  Avound  during  the  course  of  the  dissection. 
Drainage  with  tubes  through  small  stab  wounds  on  each  side  of  the  neck 
should  be  established. 


THE  CEEVICAL  SYMPATHETIC 

Bemoval  of  the  cervical  sympathetic  ganglia  was  formerly  recommended 
by  Jonnesco  for  exophthalmic  goiter.  It  is  no  longer  used  for  this  purpose 
but  has  been  occasionally  done  for  unimproved  exophthalmos  after  the  thy- 
roid gland  has  been  operated  upon  and  the  other  symptoms  have  disappeared. 
The  operation  has  been  done  by  C.  H.  Mayo  in  those  cases  of  extreme  exoph- 
thalmic and  nervous  symptoms  that  are  out  of  proportion  to  the  size  of  the 
thyroid.  He  removes  the  superior  and  sometimes  the  middle  sympathetic 
ganglia,  and  at  the  same  time  ties  the  superior  thyroid  vessels.  The  operation 
is  done  through  an  incision  whose  center  is  on  a  level  with  the  bifurcation  of  the 
common  carotid  artery.  The  sternomastoid  muscle  is  retracted  outward  and 
the  sheath  containing  the  carotid  vessels  and  the  vagus  and  internal  jugu- 
lar vein  is  retracted  inward.  The  superior  sympathetic  ganglion  is  about 
one-eighth  to  one-fourth  of  an  inch  wide  and  has  many  branches.  After 
dividing  the  branches  the  upper  ganglion  is  removed.  The  connecting  nerves 
of  the  middle  f^ervical  p,'anglion  are  cut,  or  this  ganglion  may  also  be  re- 
moved. 


326  OPERATIVE    SURGERY 

In  Jonnesco's  operation  the  incision  is  made  behind  the  mastoid  process 
along  the  posterior  border  of  the  sternomastoid  muscle  to  just  below  the 
clavicle.  The  external  jugular  vein  is  doubly  ligated  and  divided,  the  fibers 
of  the  sternomastoid  muscle  are  split,  and  the  ganglion  is  approached 
through  this  muscle  splitting  incision.  The  inner  portion  of  the  sternomas- 
toid muscle  along  with  the  vessels  and  nerves  in  the  carotid  sheath  is  re- 
tracted inward,  and  upward.  The  sympathetic  nerves  are  found  either  on  the 
posterior  surface  of  the  sheath  containing  the  vessels  which  have  been  re- 
tracted inward  or  on  the  vertebral  column  in  a  special  sheath.  The  sympa- 
thetic nerve  is  followed  upward  until  it  is  seen  to  communicate  with  the  supe- 
rior sympathetic  ganglion.  The  ganglion  is  dissected  bluntly  from  below  up- 
ward, its  branches  are  divided  with  scissors  and  the  ganglion  is  removed.  The 
inferior  thyroid  artery,  as  it  crosses  under  the  common  carotid,  is  surrounded  by 
a  dense  nervous  plexus  which  consist  of  the  sympathetic  trunk  with  its 
branches.  At  this  point  enlargement  of  the  sympathetic  nerve  forms  the 
middle  cervical  ganglion.  By  making  traction  on  the  nerve  trunk  it  is  fol- 
lowed downward  and  the  nerve  is  elevated  and  separated  from  the  inferior 
thyroid  artery.  The  inferior  ganglion  is  the  most  difficult  to  remove  and  its 
removal  is  usually  unnecessary.  It  lies  deep  in  the  base  of  the  neck,  just  above  the 
pleura,  behind  the  clavicle  and  against  the  head  of  the  first  rib  between 
the  scalenus  anticus  and  longus  colli  muscles.  The  trunk  of  the  sympa- 
thetic is  the  guide  to  the  ganglion  which  lies  sometimes  internal  and  some- 
times external  to  the  vertebral  artery.  The  inferior  sympathetic  ganglion 
is  adherent  to  the  vertebral  artery  which  makes  its  separation  difficult.  After 
exposing  the  vertebral  artery  the  ganglion  is  caught  with  forceps  and  isolated 
from  the  artery  externally  and  the  rib  and  spine  internally.  Its  nervous  con- 
nection is  severed  and  the  ganglion  removed.  The  wound  is  closed  carefully 
without  drainage. 

This  extensive  operation  is  rarely  if  ever  indicated,  though  removal  of 
the  upper  and  possibly  the  middle,  cervical  sympathetic  ganglion  as  prac- 
ticed by  C.  H.  Mayo,  may  sometimes  be  beneficial  under  conditions  that  have 
been  described  by  him. 

THE  THYROID  GLAND 

A  simple  goiter  may  be  removed  with  the  same  general  precautions  ob- 
served in  operating  on  any  tumor  of  the  neck,  but  a  goiter  with  hyperthy- 
roidism introduces,  a  distinctively  different  problem.  In  the  exophthalmic 
type  of  goiter  thyroidectomy  should  not  be  done  during  the  acute  exacerba- 
tion of  the  disease  when  the  pulse  is  running  120  or  more  and  the  symptoms 
of  hyperthyroidism  are  pronounced.  Here  one  superior  thyroid  artery  is 
ligated,  preferably  under  local  anesthetic.  If  after  five  or  six  days  but  little 
reaction  occurs,  the  second  superior  thyroid  is  tied,  but  if  marked  reaction 
shown  by  rapid  pulse  and  elevation  of  temperature,  occurs  a  few  days  after 
the  first  ligation,  the  second  operation  should  be  postponed,  preferably  for 


THE    NECK 


327 


several  weeks.  If  the  second  ligation  is  followed  by  little  or  no  reaction  a 
thyroidectomy  can  be  done  in  a  week  or  ten  days  after  the  second  ligation. 
If  there  is  any  marked  reaction  after  the  second  ligation  it  is  safer  to  send  the 
patient  home  with  instructions  to  return  in  two  or  three  months  for  thyroid- 
ectomy. If  after  this  time  the  patient  has  not  improved  materially,  thyroid- 
ectomy should  not  be  attempted,  but  the  inferior  thyroids  may  be  ligated, 
or  the  goiter  injected  with  a  solution  of  quinine  and  urea,  as  has  been  very  suc- 
cessfully done  by  Leigh  Watson,  of  Chicago,  or  by  hot  water,  as  practiced 
by  Miles  Porter,  or  treatment  by  a  competent  roentgenologist  should  be  in- 
stituted. The  technic  of  ligating  the  superior  thyroids  has  been  described 
in  a  preceding  chapter  on  ligation  of  blood  vessels.  This  is  usually  done 
under  local  anesthesia. 

The  technic  of  thyroidectomy,  or  partial  thyroidectomy  as  it  should  more 
properly  be  called,  for  some  of  the  thyroid  tissue  must  always  be  left,  is  prac- 
tically the  same  for  goiters  accompanied  liy  hyperthyroidism  as  with  the 
simple  type,  except  that  the  former  are  as  a  rule,  more  vascular  and  smaller. 
The  operation  is  best  done  through  the  transverse  collar  incision  of 
Kocher.  In  a  symmetrical  goiter  this  is  made  from  one  edge  of  the  sterno- 
mastoid  muscle  to  the  other,  about  one  inch  above  the  sternum.  The  outer 
portion  of  the  incision  bends  slightly  upward.  The  incision,  of  course,  has  to 
be  modified  according  to  the  shape  and  size  of  the  goiter,  and  may  be  made 
higher  or  longer  to  render  the  thyroid  more  accessible.  The  flap  is  dissected 
to  the  larynx  and  the  lower  margin  of  the  wound  is  freed  to  the  sternum.  The 
muscles  of  the  neck  are  divided  in  the  midline  from  the  lower  border  of  the 
larynx  to  just  above  the  sternum  and  down  to  the  true  capsule  of  the  thyroid 
gland,  which  is  recognized  by  the  large  veins  and  vessels  of  the  thyroid  cours- 
ing within  it.  The  goiter  is  thoroughly  separated  from  the  ribbon  muscles  of 
the  neck  by  blunt  dissection.  Occasionally  when  the  veins  are  large  they  may 
be  ruptured  and  considerable  hemorrhage  will  occur.  If  the  separation  is 
carefully  done  with  the  finger,  and  the  proper  line  of  cleavage  is  obtained,  hem- 
orrhage is  usually  avoided.  It  is  important  to  recognize  the  thin  muscles  of 
the  neck,  otherwise  the  muscles  may  be  seriously  injured  and  the  dissection  will 
not  follow  the  capsule  of  the  thyroid,  so  that  it  will  be  difficult  or  impossible  to 
mobilize  the  goiter.  Many  goiters,  particularly  those  of  moderate  size,  can 
be  delivered  through  this  incision,  but  if  difficulty  is  encountered  the  muscles 
are  cut  across  after  doubly  clamping  them  with  heavy  Ochsner  forceps  in 
their  upper  portion,  as  advised  by  C.  H.  Mayo,  in  order  not  only  that  the  line 
of  incision  in  the  muscle  will  be  at  a  different  level  from  that  in  the  skin,  but 
to  preserve  the  nerve  supply  of  the  ribbon  muscles  which  enters  below  (Fig. 
345).  The  clamps  should  be  close  together  and  division  so  made  that  when  the 
muscles  are  united  by  suture  but  one  line  of  trauma  remains.  If  the  Ochsner 
forceps  are  placed  at  some  distance  from  each  other  and  the  division  made  be- 
tween them  there  will  be  three  lines  of  trauma,  Iavo  made  by  the  forceps  and 
one  by  the  cut.  If  the  forceps  are  placed  side  by  side  the  injury  made  by 
them  and  the  incision  will  be  so  close  that  the  muscles  which  have  usually 


328 


OPERATIVE    SURGERY 


been  stretched  by  tlie  bulging  of  the  goiter  can  be  reunited  Ijv  a  continuous 
suture  of  catgut,  wliieh  will  include  both  lines  of  trauma  made  by  tlie  forceps. 
In  this  way  a  reef  is  taken  in  the  overstretched  muscles. 

With  increasing  experience  the  surgeon  finds  less  necessity  for  cross 
cutting  the  muscles,  though  in  many  instances  it  adds  not  only  to  the  ease  of 
the  technic,  but  permits  delivery  of  the  goiter  with  much  less  trauma  than 
Avould  be  necessary  if  simply  the  midline  incision  in  the  muscle  was  employed. 
After  freeing  the  goiter  from  its  surrounding  tissue  with  the  finger  and  deliv- 
ering it  into  the  wound,  the  upper  pole  is  doubly  clamped  with  stout  Ochsner 


Fig.  345. — Exposure  of  goiter.     The   superficial  muscles  are  clamped   and  are  about  to  be  divided. 

forceps.  The  pole  is  well  isolated  and  care  taken  to  include  all  the  branches 
of  the  superior  thyroid  in  the  grasp  of  the  forceps.  Many  surgeons  advise 
using  three  forceps,  so  placed  that  tAvo  will  remain  on  the  stump  of  the  upper 
pole  after  its  division,  because  it  may  retract  and  cause  annoying  hemorrhage. 
The  tissue  that  is  adherent  to  the  goiter  posteriorly  is  put  on  a  stretch  and 
any  large  vessels -are  clamped  near  the  goiter  (Fig.  346).  After  clamping  and 
dividing  the  upper  pole  the  dissection  is  carried  from  above  downward,  so 
releasing  the  low^er  pole.  The  posterior  capsule  of  the  goiter  is  left  along  wdth 
a  small  attached  portion  of  thyroid  tissue  in  order  not  to  wound  the  recurrent 
laryngeal  nerve.  The  trachea  and  thyroid  are  identified  and  an  effort  is  made 
not  to  expose  the  trachea  but  to  dissect  close  to  the  thyroid  Avhile  removing  it 


THE    NECK 


329 


from  the  Iraeliea.  In  this  Avay  a  thin  layer  of  tissue  is  left  over  the  trachea 
and  small  nerves  in  the  tracheal  Avall,  which  might  cause  irritation  if  exposed, 
are  protected  by  this  layer  of  tissue.  If  the  goiter  extends  on  each  side,  dis- 
section is  carried  across  the  midline  and  the  goiter  on  the  other  side  is  well 
mobilized.  The  vessels  are  clamped  first  from  above  downward,  taking  care 
to  leave  some  thyroid  tissue  at  the  upper  pole  and  around  the  region  of  the 
entrance  of  the  inferior  thyroid  artery,  which  will  also  protect  the  recurrent 
laryngeal  nerve.  The  vessels  are  tied  carefully  with  catgut.  All  oozing  sur- 
faces must  be  thoroughly  controlled  before  closing  the  wound.     If  the  raw 


Fig.    3-46. — The   goiter  has   been   partiallj'   mobilized.      The   superior   thyroid  vessels   are   ready   for  clamping 

and  division. 


surfaces  of  the  thyroid  that  are  left  continue  to  bleed  they  are  whipped  over 
with  catgut.  If  the  muscles  have  been  cut  across  they  are  united  by  a  con- 
tinuous suture  of  plain  catgut.  The  incision  in  the  muscle  in  the  midline  is 
similarly  sutured  and  a  small  drainage  tube  is  inserted  at  the  lowest  end  of  the 
midline  incision  in  the  muscle.  This  appears  to  be  necessary  to  prevent  a 
large  accumulation  of  serum  that  would  otherwise  occur. 

The  platysma  and  subcutaneous  tissues  are  united  by  a  continuous  suture 
of  fine  plain  catgut.  The  skin  is  brought  together  in  two  sections  by  a  subcu- 
ticular suture  of  fine  silkworm-gut.  The  tube,  which  is  a  very  small  one,  pro- 
trudes from  the  middle  of  the  incision.    The  continuous  suture  of  each  section 


330  OPERATIVE    SURGERY 

ends  at  the  tube  and  when  the  tube  is  removed  about  the  third  or  fourth  day 
after  operation  the  skin  wound  falls  together  without  further  suturing. 

Sometimes  the  conformation  of  the  goiter  may  be  such  as  to  make  it  wise 
to  approach  the  growth  from  the  midline.  D.  C.  Balfour  has  described  a 
technic  in  which  this  type  of  operation  may  be  done.  Willard  Bartlett  has 
special  forceps  for  compressing  the  thyroid  near  its  poles.  The  goiter  is 
divided  in  the  midline,  dissected  from  the  midline  outward,  clamped  by  for- 
ceps and  excised  in  a  wedge-shaped  manner  so  that  the  raw  surfaces  in  the 
goiter  are  approximated  with  continuous  sutures  which  control  the  bleeding. 
Bartlett 's  technic  does  not  necessarily  include  division  in  the  midline,  though 
in  the  operation  described  by  him  this  may  be  done  if  it  facilitates  matters. 
He  first  clamps  and  divides  the  superior  thjToid  at  the  goiter  and  then  com- 
presses the  vascular  margin  of  the  goiter  with  his  forceps  introduced  from 
below. 


CHAPTER  XVIII 
OPERATIONS  ON  THE  UPPER  EXTREMITIES 

AMPUTATIONS 

Amputations  were  formerly  the  glory  of  surgery  because  in  preantisep- 
tic  days  they  were  the  chief  operations  that  were  performed.  With  the 
progress  of  surgery,  however,  efforts  to  save  a  limb  instead  of  to  destroy 
it,  have  been  greater,  so  gradually  amputation  has  come  to  be  looked  upon 
as  a  confession  of  failure  to  save  the  limb  and  of  inability  to  conserve  its 
function. 

Amputation  of  the  upper  extremity  or  of  a  portion  of  the  upper  extremity 
may,  however,  be  indicated  either  as  a  result  of  extreme  trauma  or  of  gan- 
grene, infection,  or  malignant  growths.  Amputation  for  infection  and  trauma 
is  done  much  less  frequently  than  formerly  because  the  modern  treatment  of 
wounds  often  succeeds  in  saving  a  limb  even  when  infection  is  severe.  The 
same  is  true  of  severe  injuries.  Probably  the  greatest  contribution  to  mili- 
tary surgery  during  the  AVorld  War  was  debridement,  which  is  excising  the 
injured  tissue.  If  this  is  done  a  few  hours  after  the  wound  is  made  or  dur- 
ing the  period  of  contamination  before  infection  has  set  in,  the  raw  surfaces 
may  be  sutured,  or  if  that  is  impossible  the  wound  may  be  treated  as  though 
it  were  a  clean  wound,  and  infection  will  seldom  occur.  After  the  first  few 
hours,  however,  when  the  period  of  infection  has  begun  and  bacteria  are 
multiplying  in  the  tissues,  debridement  will  merely  expose  freshly  cut  sur- 
faces to  the  infective  germs  with  which  the  tissues  are  infiltrated.  Here,  fre- 
quent dressings  of  antiseptics  or  treatment  by  the  Carrel-Dakin  method  will 
often  result  in  cure  in  cases  that  appear  to  admit  only  of  amputation. 

It  must  be  borne  in  mind  that  it  is  much  easier  to  amputate  a  limb 
than  it  is  to  save  it,  and  while  the  patient's  life  should  not  be  too  greatly 
risked  in  order  to  save  his  limb,  the  operator  should  be  reasonably  sure  that 
amputation  is  distinctly  indicated  before  resorting  to  it. 

In  malignant  growths  amputation  is  not  frequently  justified.  Bone 
cysts  and  so-called  giant  cell  sarcomas  can  be  treated  conservatively  by  resec- 
tion with  bone  grafting  if  necessary,  or  by  thorough  curetting  and  packing 
the  cavity.  If  the  growth  is  a  periosteal  sarcoma,  amputation  does  but  little 
good,  for  hardly  more  than  four  per  cent  of  periosteal  sarcomas  are  eventually 
saved  by  amputation. 

In  amputation  there  are  certain  general  principles  which  should  be 
discussed.  Controlling  hemorrhage  is  one  of  the  chief  problems.  This  be- 
comes increasingly  grave  the  nearer  the  site  of  amputation  approaches  the 
body.     A  tourniquet  is  the  standard  orthodox  method  of  controlling  hem- 

331 


332  Ol'ERATIVE    SURGERY 

orrliage  and  may  iLsiially  be  employed.  It  should  be  placed  sufficiently 
far  above  the  site  of  operation  not  to  be  in  the  way  of  the  operator  and 
preferably  at  some  distance  from  a  joint  if  it  is  a  large  joint.  A  touriii(iuet 
on  the  upper  arm  and  thigh  is  more  satisfactory  than  on  the  leg  or  forearm, 
because  the  presence  of  two  bones  in  these  latter  regions  sometimes  prevents 
the  action  of  the  tourniquet  from  constricting  the  soft  parts.  It  is  best  to  place 
a  towel  next  to  the  arm  if  a  tourniquet  is  used  so  that  the  skin  will  not  be 
injured.  An  excellent  tourniquet  is  a  broad  thin  rubber  band,  which  is 
wrapped  around  a  number  of  times  and  controlled  by  tying  the  ends  together 
or  by  fastening  Avith  a  clamp.  A  large,  soft,  black  rubber  tube  also  makes  a 
good  tourniquet  and  in  amputation  about  the  shoulder  joint  is  superior  to  any 
other  kind  of  tourniquet.  In  an  emergency  a  handkerchief  or  a  towel  can  be 
used  very  satisfactorily.  After  tying  the  handkerchief  or  towel  tightly,  a 
cane,  or  a  long  stick,  is  inserted  just  beneath  the  towel  and  twisted  until 
sufficient  pressure  is  obtained.  A  pair  of  suspenders  makes  an  excellent 
tourniquet  in  an  emergency. 

In  operations  on  the  fingers  or  thumb  a  small  soft  rubber  tube  or  a  soft 
rubber  catheter  may  be  used  for  a  tourniquet.  An  ordinary  rubber  band  is  a 
good  tourniquet  for  the  finger.  If  a  soft  rubber  catheter  is  to  be  used,  it  is 
best  applied  by  wrapping  it  once  completely  around  the  base  of  the  finger  and 
then  carrying  the  ends  across  the  back  of  the  hand  and  around  the  wrist  in  a 
figure-of-eight  turn  and  clamping  the  two  ends  together  with  a  hemostatic 
forceps. 

Tourniquets,  however,  are  by  no  means  free  from  danger.  For  this  rea- 
son many  industrial  surgeons  do  not  recommend  them.  A  tourniquet  may 
often  be  uselessly  applied  and  if  not  tight  enough  will  merely  constrict  the 
venous  circulation  and  promote  bleeding  while  if  it  is  too  tight  actual  damage 
may  be  done.  The  use  of  a  tourniquet  is  also  unwise  in  those  cases  in  Avhich 
the  patient's  resistance  is  at  the  lowest  ebb,  but  in  which  amputation  is  clearly 
necessary  because  of  gangrene.  Here  with  low  general  vitality  and  impover- 
ished circulation  to  the  limb,  particularly  in  arterial  disease,  the  blood  vessels 
may  not  only  be  injured  by  the  application  of  the  tourniquet,  but  the  complete 
cutting  off  of  nutrition  from  the  tissues  of  the  stump  even  for  the  short  time 
that  is  necessary  to  perform  the  operation,  has  an  injurious  effect  upon  the 
resistance  of  these  tissues  and  may  embarrass  the  healing  of  the  flap.  In  the 
presence  of  marked  inflammation  a  tourniquet  should  be  applied  well  above  the 
inflammation,  or  if  this  is  impossible  it  should  not  be  applied  at  all. 

The  Esmarch  method  of  controlling  bleeding  has  largely  fallen  into  dis- 
use. This  consists  in  beginning  at  the  fingers  with  a  rubber  bandage  and 
encircling  the  limb  upward  from  the  fingers,  appljdng  the  l)andage  so  snugly 
as  to  drive  out  all  the  blood.  When  the  bandage  reaches  above  the  elbow  a 
tourniquet  is  applied  and  then  the  Esmarch  bandage  is  released.  This  method 
secures  a  bloodless  field,  but  if  amputation  is  done  for  infection  the  application 
of  Esmarch 's  bandage  would,  of  course,  be  exceedingly  dangerous  and  would 
force  into  the  circulation  the  products  of  the  inflammation.     Even  in  aseptic 


THK  iri'i'iat  KXTRianTiES  333 

injuries  llic  ascplic  products  ol'  injured  tissues,  Avhieli  iire  now  regarded  as 
tlie  eliiel'  cause  of  sliocd-c,  may  he  dislodged  and  forced  into  tlie  circulation  in 
ovorwhelmiug'  amounts.  In  malignant  diseases  the  Esmai'cli  bandage  would, 
of  course,  force  cancerous  cells  into  the  circulation. 

Before  applying  a  tourniquet  the  lind)  sliould  be  elevated  for  a  few 
minutes  so  that  the  venous  1)lood  that  wovdd  naturally  drain  out  of  the  limb 
because  of  gravity  can  be  saved.  If  but  little  blood  is  lost  during  the 
amputation  and  the  patient  has  not  bled  previously  the  total  amount  of  blood 
in  proportion  to  the  tissues  wdll  probably  not  be  changed,  because  with  am- 
putation of  the  extremity  there  is  less  tissue  to  be  supplied  with  blood. 

With  a  good  knoAvledge  of  anatomy  and  a  reasonably  careful  dissection 
even  amputation  at  the  shoulder-joint  or  at  the  hip-joint  can  be  done  without 
a  tourniquet  and  wdth  no  large  loss  of  blood,  particularly  in  patients  who  are 
not  very  stout.  A  tourniquet  in  these  regions,  however,  is  as  a  rule,  desirable. 
If  a  tourniquet  is  not  to  be  used,  the  incision  should  be  so  shaped  that  the 
large  vessels  will  be  exposed  at  an  early  stage  of  the  operation.  They  can 
then  be  doubly  clamped,  divided,  and  ligated  and  thus  the  main  source  of 
hemorrhage  is  controlled. 

A  good  knowledge  of  anatomy  is  essential  in  amputating.  The  flaps 
should  be  cut  as  broad  as  possible  so  the  nutrition  w-ill  be  abundant  and  the 
vessels  should  be  ligated,  preferably  wdth  catgut,  before  the  tourniquet  is 
removed.  In  amputations  near  the  body  where  the  vessels  are  large  there 
should  be  two  ligatures  on  the  vessels,  as  recommended  in  the  ligation  in 
continuity.  The  ligature  nearest  the  heart  absorbs  the  impulse  of  the  arterial 
current  and  makes  the  conditions  of  healing  at  the  second  ligature  distally 
placed  much  better,  as  this  second  ligature  is  not  subjected  to  the  strain  and 
impulse  of  the  arterial  current  and  the  tissues  it  encircles  are  relatively  at  rest. 

In  amputations,  particularly  the  larger  amputations,  it  is  best  to  use  drain- 
age. This  may  be  removed  after  tw^enty-four  or  forty-eight  hours  in  cases 
that  are  clean,  but  there  is  usually  considerable  outpour  from  the  severed 
lymphatics,  which,  if  not  drained  away,  is  absorbed  with  some  diiftculty  by 
the  tissues  and  interferes  wdth  the  nutrition  of  the  flaps,  because  it  prevents 
them  from  coming  in  contact  with  raw  surfaces  having  a  good  blood  supply. 

In  amputation  of  the  finger,  drainage  is  not  necessary.  If  it  is  felt  that 
the  stump  is  probably  infected,  or  if  the  character  of  infection  for  which  the 
amputation  is  done  is  highly  virulent,  the  flaps  may  be  either  not  sutured  at 
all,  or,  better  still,  sutures  of  silkworm-gut  can  be  placed  but  not  tied  and 
the  flaps  left  open  and  packed  loosely  with  iodoform  gauze.  As  has  been 
explained  in  the  chapter  on  drainage,  this  will  cause  a  reversal  of  the  circula- 
tion of  the  lymph  channels  and  so  Avill  prevent  the  absorption  of  much 
of  the  septic  material  that  would  otherwise  be  carried  along  the  regular 
channels  of  the  lymphatics  toward  the  body.  After  five  or  six  days  if 
the  tendency  to  infection  has  been  overcome  the  gauze  is  loosened  by  soak- 
ing it  in  a  mild  antiseptic  solution  and  by  the  application  of  peroxide  of 
hydrogen.     It  can  then  be  removed  and  the  sutures  tied. 


334  OPERATIVE    SURGERY 

The  treatment  of  the  bone  in  amputations  involves  a  very  definite  pro- 
cedure. If  the  amputation  is  through  a  joint,  or  in  other  words,  is  a  disarticu- 
lation, care  must  be  taken  not  to  injure  the  cartila^'inous  coating  of  the  joint. 
If  the  amputation  is  through  the  continuity  of  the  bone  the  end  of  the  bone 
is  scraped  out  thoroughly  Avith  a  curet,  to  remove  the  endosteum  and  the 
medulla,  for  a  distance  of  about  an  inch.  The  periosteum  is  also  removed  from 
the  external  portion  of  the  bone  for  about  the  same  distance  and  the  sharp 
margins  are  trimmed  "with  forceps  or  with  a  coarse  file.  The  method  of 
using  a  periosteal  flap  in  amputation  has  been  discredited.  While  it  is 
now  known  that  the  outer  layers  of  the  i^eriosteal  flap  have  nothing  to 
do  with  regeneration  of  bone,  the  periosteum  often  promotes  unnecessary 
callus  and  painful  nodules ;  for  when  the  periosteum  is  stripped  up  to  make  a 
flap  small  portions  of  the  cortex  of  the  bone  and  the  cambium  layer  of  the  perios- 
teum are  removed  and  these  cause  deposits  of  bone  at  irregular  points. 

The  so-called  guillotine  operation  has  been  used  in  severe  infections,  or 
when  there  is  great  need  for  haste.  In  this  method  the  limb  is  practically 
chopped  off,  all  of  the  tissue  being  divided  at  about  the  same  level.  Naturally 
the  muscles  contract  considerably  and  the  bone  protrudes.  Often  a  secondary 
amputation  has  to  be  done  later  on.  While  indications  for  the  guillotine  ampu- 
tation in  the  arm  or  forearm  do  not  usually  exist,  it  is  sometimes  a  good 
procedure  in  amputating  the  finger  where  an  effort  is  made  to  preserve  as 
much  of  the  finger  as  possible. 

In  every  amputation  the  nerves  should  be  cleanly  divided  with  a  sharp 
knife.  The  nerve  should  be  pulled  down  and  as  much  of  it  cut  off  as  possible 
in  order  that  the  stump  may  retract  and  not  be  caught  in  the  scar  of  the 
healing  flaps,  which  is  the  frequent  cause  of  painful  stumps.  The  neuroma 
which  forms  on  the  end  of  a  nerve  after  its  section  is  usually  not  painful  if 
there  is  no  infection  and  if  the  scar  tissue  in  the  neuroma  is  not  excessive. 

One  of  the  most  unfortunate  complications  of  the  stump  is  a  painful 
stump,  which  may  be  due  to  adhesions  to  the  bone  or  to  neuromas.  Neuromas 
consist  of  connective  tissue  about  the  end  of  the  nerve  into  which  grow  the  neu- 
raxes  from  the  central  portion  of  the  nerve.  If  the  end  of  the  nerve  is  near  the 
other  scar  tissue,  or  if  there  is  considerable  irritation,  there  is  an  abnormally 
large  amount  of  scar  tissue  which  produces  a  large  neuroma  that  will  almost 
certainly  be  painful.  Huber  and  Dean  Lewis  have  shown  that  if  the  last  inch 
of  a  nerve  be  injected  with  alcohol  at  the  time  of  amputation  no  neuroma  Avill 
form,  as  the  injection  destroys  the  axones  and  does  away  with  the  tendency 
for  them  to  grow  downward  into  the  end  of  the  stump.  This  practice  is  simple 
and  should  be  carried  out. 

While  there  are  many  types  of  amputations,  there  are  general  principles 
applying  to  them  all  which  reduce  the  matter  to  the  selection  of  that 
operation  best  fitted  for  the  particular  case.  Often  the  character  of  an 
injury  Avill  make  it  necessary  to  modify  the  shape  of  the  flaps.  It  must  be 
borne  in  mind  that  the  flap  should  be  well  nourished  and  not  too  long,  and 


THK    UI'l'KR    EXTRKMITIES  335 

}>;n't  ic'iilai'l\'  not  too  slioi't,  and  it'  an  arliCicial  liiub  is  to  be  worn  llie  scar 
pi'ot'orably  slionid  not  be  at  the  apex  ol'  the  st\itii|). 

The  amount  of  soft  tissue  necessary  to  cover  a  bone  in  amputation  is,  in 
rlie  eirenhir  amputation,  a  distance  of  about  three-fourths  the  diameter  of 
the  limb  from  the  point  of  division  of  the  bone  to  the  end  of  the  flap.  This 
is  equivalent  to  about  one-fourth  of  the  circumference  of  the  limb.  When 
a  single  flap  or  unequal  flaps  are  used,  the  total  length  below  the  bone 
should  be  equivalent  to  about  one  and  one-half  times  the  diameter  of  the 
limb,  which  is  one-half  of  the  circumference,  as  the  diameter  is  about  one- 
third  of  the  circumference.  The  skin  and  superficial  fascia  always  con- 
tract considerably  after  incision,  so  full  allowance  should  be  made  for  this 
in  any  amputation.  In  amputating  a  large  limb  retraction  is  greater  than 
in  a  small  limb.  It  is  better  to  have  a  flap  a  little  too  long  than  too  short, 
because  swelling  makes  tension  and  often  contraction  occurs  later  on.  If, 
however,  there  is  markedly  redundant  tissue  it  can  be  easily  excised  before 
the  flap  is  sutured.  In  the  lower  part  of  the  thigh  and  in  the  arm  the  ten- 
dency to  retraction  of  the  soft  parts  is  very  great  and  here  flaps  should 
be  made  equivalent  to  about  twice  the  diameter  of  the  limb  or  two-thirds 
of  the  circuniference.  In  a  circular  amputation  in  this  region  the  distance 
between  the  skin  incision  and  the  point  of  division  of  the  bone  should  equal 
the  diameter  of  the  limb. 

When  an  incision  is  made  the  skin  is  firmly  grasped  and  retracted  upward 
to  make  as  much  allowance  as  possible  for  the  natural  retraction.  After 
the  skin  and  fascia  have  been  cut  the  muscles  are  incised.  If  a  flap  opera- 
tion is  made,  as  much  fat  and  superficial  fascia  is  turned  back  wdth  the 
skin  as  possible  in  order  to  provide  nutrition  for  the  flap.  If  it  is  intended 
to  use  a  muscular  flap,  the  muscles  are  cut  obliquely  from  without  inward 
by  dissection  after  the  fascia  has  been  incised.  It  is  best,  as  a  rule,  to  have 
a  muscular  covering  for  the  bone. 

A  circular  amputation  is  quickly  done  and  has  many  advantages.  It 
is  applicable  in  the  middle  of  the  arm,  of  the  forearm,  and  of  the  thigh.  The 
skin  is  divided  circularly  down  through  the  fascia  and  is  retracted,  exposing 
the  superflcial  muscles  wdiich  are  divided  by  a  circular  incision.  This  layer 
of  muscles  is  retracted  and  the  deep  layer  of  muscles  is  divided  at  the  level  at 
which  the  bone  is  to  be  sawed.  This  makes  a  funnel  shaped  wound  with  the  bone 
at  the  bottom  and  a  satisfactory  muscular  covering.  The  skin  has  a  maximum 
amount  of  nutrition  as  its  vessels  are  not  even  interfered  wdth  by  a  longi- 
tudinal incision.  Sometimes  a  cuff  of  skin  and  superflcial  fascia  is  rolled 
back  in  order  to  get  a  sufficient  amount  of  covering.  This  is  called  the  cuff 
operation  and  is  merely  a  modification  of  the  circular  method. 

The  old  method  of  transfixion  Avith  a  long  knife  is  but  seldom  used,  the 
flaps  now  being  dissected  from  without  wdth  a  sharp  scalpel.  The  chief  ob- 
jection to  the  transfixion  method  is  that  it  often  splits  and  divides  vessels 
and  nerves  and  makes  their  identification  difficult  and  at  the  same  time  does 
not  fashion  the  muscular  flap  as  accurately  as  a  careful  dissection  would. 


336  OPERATIVE    SURGERY 

Modifications  of  the  circular  and  various  forms  of  flap  amputations  are, 
of  course,  often  necessary  because  the  flap  should  he  so  fashioned  as  to 
secure  the  best  nuti-ition,  and  as  amputations  are  often  done  for  injury  it 
may  frequently  be  necessary  to  do  an  atypical  amputation  in  order  to  secure 
a  satisfactory  flap  without  sacrificing  too  much  of  the  stump. 

After  the  flaps  have  been  cut  an  incision  is  made  through  the  periosteum 
down  to  the  bone,  about  half  an  inch  above  the  desired  point  of  section  with 
the  saw.  In  order  to  expose  the  bone  the  flaps  are  retracted  by  placing 
two  towels  over  them  snugly  against  the  bone.  Where  there  are  two  bones, 
as  in  the  forearm  and  in  the  leg,  three  towels  or  three  special  pieces  of  cloth 
are  necessarj^  After  retracting  the  flaps  the  periosteum  is  divided  with  a 
circular  incision  and  scraped  down  and  the  bone  is  divided  about  one-half 
an  inch  below  the  incision  in  the  periosteum.  The  medulla  and  endosteum 
are  carefully  curetted  away  to  about  one-half  an  inch  from  the  end  of  the 
bone.  This  makes  a  much  better  and  a  much  less  painful  end  of  the  bone 
than  by  using  periosteal  flaps.  The  vessels  are  identified,  clamped,  and  care- 
fully tied,  preferably  with  catgut.  The  larger  vessels  are  tied  at  two  places 
about  one-fourth  inch  from  each  other.  If  a  tourniquet  is  used  it  is  removed 
and  other  bleeding  points  are  clamped  and  tied.  If  muscular  covering  is 
possible  the  muscle  is  sutured  over  the  bone  with  interrupted  sutures  of 
catgut.  The  sutures  are  not  tied  tightly  and  no  more  are  placed  than 
necessary  to  obtain  approximation.  Sometimes  the  suturing  of  the  fascial 
covering  of  the  muscles  brings  the  muscles  into  position.  This  fascia  is  sutured 
wherever  possible.  If  there  is  redundant  tissue  either  in  the  muscle  or 
skin  it  is  trimmed  away  but  this  ought  not  to  be  done  until  it  is  quite  certain 
that  the  tissue  cannot  be  utilized  in  the  stump. 

If  a  flap  amputation  is  done  the  flaps  are,  if  possible,  so  placed  that  a 
drainage  tube  in  the  angle  of  the  flap  will  be  at  the  most  dependent  portion. 
If  a  circular  amputation  is  performed  it  should  preferably  be  sutured  in  an 
anteroposterior  direction  so  drainage  can  be  inserted  at  the  dependent  por- 
tion of  the  wound.  The  skin  is  best  closed  with  interrupted  sutures  of 
silk  or  silkworm-gut.  The  drainage  tube  of  rubber  is  removed  at  the  end  of 
forty-eight  hours  if  healing  is  satisfactory. 

Besides  the  standard  flaps  and  the  circular  method,  other  modifications 
are  used,  such  as  the  racket  incision,  which  is  a  circular  or  slightly  oval 
incision  combined  with  a  straight  vertical  incision.  The  oval  method  of 
amputating  is  a  modification  of  the  circular  in  which  the  incision  is  made 
in  an  oval  manner  and  brings  the  scar  to  the  side  of  the  stump  instead  of 
being  at  the  apex.  Elliptical  amputation  is  practically  the  same  as  the  oval, 
but  is  somewhat  more  inclined  to  the  form  of  a  flap  and  is  chiefly  used  in 
amputations  or  disarticulations  at  the  joints. 

In  amputation  of  the  fingers  or  hand  the  palmar  flap  should  always  be 
longer  because  the  skin  of  the  palm  is  thick  and  bears  usage  better  than 
the  skin  on  the  dorsal  surface  of  the  hand,  and  also  because  it  is  better  nour- 
ished (Figs.  347  and  348).     In  amputation  of  the  fingers  a  tourniquet  may 


THE   UPPER   EXTREMITIES  337 

be  placed,  as  has  already  been  described,  using  a  ru1)ber  band,  or  a  soft 
rubber  catheter.  As  a  rule  it  is  best  to  amputate  here  through  a  joint.  It 
must  be  borne  in  mind  that  the  distal  ends  of  the  metacarpal  bone  of  the 
phalanges  form  the  knuckles  so  that  the  plane  of  the  joint  is  distal  to  the 
knuckle,  and  the  flaps  should  be  shaped  accordingly.  The  webs  of  the  fingers 
are  about  three-quarters  of  an  inch  below  the  metacarpal  joints.  In  planning 
an  amputation  of  the  finger  the  palmar  flap  should  always  be  the  longer 
Avherever  possil)le.  It  may  be  long  enough  to  cover  the  whole  stump  and  be 
united  to  the  dorsal  incision  of  the  amputation,  or  there  may  be  a  short 
dorsal  flap  and  a  long  palmar  flap.  The  anatomy  of  the  finger  and  the  in- 
sertion of  the  flexor  and  extensor  tendons  should  be  borne  in  mind.  The 
superficial  flexors  of  the  fingers  are  inserted  into  the  sides  of  the  middle 
phalanges  and  the  deep  flexors,  after  splitting  the  superficial  flexors,  are  in- 
serted into  the  bases  of  the  last  phalanges.  The  extensor  tendons,  however,  are 
inserted  along  the  whole  of  the  back  of  the  dorsal  surfaces  of  the  phalanges. 
Where  it  is  thought  best  to  save  as  much  of  the  finger  as  possible   a 


Fig.     347.— Line     of     incision     for     amputation     of  Fig.    348. — Showing    the    method    of    forming    long 

distal  phalanx   of   finger.  palmar   flap   in    amputation    of   finger. 

guillotine  operation  can  be  done,  dividing  all  the  tissues  at  the  same  level. 
This,  however,  usually  results  in  a  painful  stump.  J.  S.  Davis,  of  Baltimore, 
has  placed  a  celluloid  ring  around  the  stump,  which  appears  to  promote 
granulations  and  to  give  a  thicker  covering  for  the  end  of  the  bone  than  is  ob- 
tained without  this  treatment.  It  is  particularly  desirable  to  save  as  much 
of  the  index  finger  and  of  the  thumb  as  possible. 

The  flexor  tendons  of  the  thumb  and  of  the  little  finger  have  a  sheath  that 
communicates  with  the  large  palmar  synovial  sac,  and  infection  from  these 
two  points  is  more  serious  than  would  be  infection  from  the  other  fingers. 
The  flexor  tendons,  particularly  of  the  index  or  little  finger,  should  be  at- 
tached to  their  sheath  or  to  the  periosteum  by  a  few  sutures  when  the  sheath 
is  opened  so  as  to  preserve  the  action  of  these  tendons.  The  finger  should 
be  flexed  when  cutting  the  dorsal  flap  and  extended  when  cutting  the  palmar 
flap.  When  an  amputation  is  made  through  a  joint  as  much  as  possible  of  the 
capsular  ligament  should  be  saved  in  order  to  cover  the  end  of  the  bone 
(Fig.  349).  In  amputating  through  a  joint,  the  joint  is  opened  on  the  back 
first,  cutting  the  extensor  tendon,  then  dividing  the  lateral  attachments,  and 


338  OI'KRATIVE    SI'RGERY 

last  of  all  C'iittiiii>-  the  flexor  toiulon.  The  tendons  should  be  cut  long  enough 
to  allow  them  to  be  reattached. 

Amputation  throufrh  the  last  phalanx  should  be  done  if  possible  by  a 
single  palmar  flap.  After  outlining  the  flap  with  a  knife  the  extensor  tendon 
is  cut  and  the  joint  opened  on  its  back,  as  has  just  been  described.  The  lat- 
eral attachments  are  cut  and  lastly  the  flexor  tendon.  The  flexor  tendon 
is  fixed  to  its  sheath  or  to  the  periosteum  in  its  neighborhood  by  fine  tanned 
or  chromic  catgut.  After  tying  with  catgut  the  digital  arteries  which  are 
on  the  sides  of  the  stump,  the  palmar  flap  is  sutured  to  the  dorsal  flap  by 
interrupted  fine  silk  or  fine  silkworm-gut  sutures. 

If  amputation  is  done  through  a  joint,  that  is,  if  a  disarticulation  is 
done,  it  will  require  a  longer  flap  to  cover  the  bone  than  where  the  bone  is 
divided.  If  it  is  impractical  to  take  a  long  palmar  flap,  the  flaps  should  at 
least  be  so  fashioned  that  the  palmar  flap  will  be  longer  than  the  dorsal  flap. 

The  same  method  is  used  in  amputating  the  second  phalanx.  The  flaps, 
as  shown  in  the  illustration,  should  not  have  sharp  corners,  but  should  be 
rounded.  Occasionally  it  is  necessary  to  take  a  flap  from  the  lateral  a.spect 
of  the  finger  instead  of  the  palmar.     This  variation  in  the  technic  may  be 


Fig.    349. — Amputation   of  the   finger;   A,   through   first   phalanx  by    equal   flaps;    B,   through   first   phalangeal 
joint  by  long  palmar  and   short   dorsal   flaps;    C,  amputation  by   long  palmar  flap. 

demanded  by  the  situation  of  the  lesion.     The  bone   is  divided  with  a   saw, 
as  bone  forceps  may  splinter  the  bone. 

Amputation  or  disarticulation  of  the  finger  at  the  metacarpophalangeal 
joint  may  be  done  by  the  oval  or  by  the  racket  incision.  The  racket  incision 
resembles  a  Y-shaped  incision  when  looked  at  from  the  back  of  the  hand  (Fig. 
350).  It  begins  on  the  back  of  the  metacarpal  bone,  a  short  distance  proxi- 
mal to  its  head,  passes  downward  crossing  the  knuckle  and  then  goes  obliquely 
around  the  palmar  aspect  of  the  finger  a  short  distance  distal  below  the 
web  of  the  finger.  It  is  then  carried  around  the  other  side  of  the  finger  in  a 
symmetrical  manner  to  the  point  of  beginning.  This  may  be  made  in  two 
incisions,  as  in  cutting  a  flap,  so  that  the  incisions  diverge  downward  from 
the  back  of  the  knuckle.  After  the  skin  and  fascia  have  been  cut  and 
are  retracted  the  extensor  tendon  and  then  the  capsular  ligament  are  di- 
vided, saving  as  much  of  the  ligament  as  possible.  The  flexor  tendons 
are  divided,  as  has  been  described,  and  are  fastened  to  their  sheaths  with 
sutures.  The  digital  arteries  are  tied.  The  wound  is  closed  by  suturing 
together  the  edges  in  an  anteroposterior  direction  so  that  the  scar  forms  a 
line  leading  from  the   back   of   the   hand    over   the   head   of   the   metacarpal 


Till';  1!|'Im:i:  iixtjikmith:;-; 


339 


hoin'  1(1  llic  palmar  siirrarc.  The  llap  iiu'lliod  can  also  Ix'  used  licrc,  particu- 
larly ill  llu-  lliimil),  llic  index  and  llic  little  fingers,  but  the  oval  or  racket 
method  is  best  in  the  middle  and  rino-  fiugei's.  If  it  is  desired  to  make  the 
hand  smaller,  the  head  of  the  metacarpal  l)one  may  be  excised,  as  its  presence 
adds  prominence  to  the  defect  because  it  accentuates  the  empty  space,  but 
it  oivos  considerably  more  strength  to  the  hand. 

Amputation  or  disarticulation  of  several  fingers  with  a  portion  or  all  of  the 
metacarpal  bones  is  done  by  a  circular  or  oval  incision.  This  may  be  converted 
into  a  flap  method  or  into  a  racket  incision  by  a  single  longitudinal  incision. 
Amputation  at  the  wrist  joint  should  not  be  done  if  amputation  at  the  carpo- 
metacari:»al  joint  is  possible.     (Figs.  351,  352.)    Amputation  of  a  single  finger 


Fig.    350. — A,    amputation    of    last   phalanx   by    palmar   flap;    B,    amputation    of   thumb    at    the   proximal    joint 
by  long  palmar  flap;   C,  disarticulation  of  iirst  metacarpal  bone  and  thumb  by  oval   method. 


with  its  adjoining  metacarpal  bone  is  done  by  a  circular  or  an  oval  incision 
around  the  base  of  the  finger  through  the  webs  of  the  finger  which  is  joined  by  a 
straight  incision  over  the  back  of  the  metacarpal  bone  through  its  whole  length. 
If  the  ring  or  middle  fingers  are  infected  often  disarticulation  of  the  correspond- 
ing metacarpal  bone  adds  symmetry  to  the  hand  but  at  the  expense  of 
strength. 

Amputation  at  the  wrist,  if  done  with  a  palmar  flap  is  begun  with  an 
incision  starting  about  half  an  inch  below  the  styloid  process  of  the  radius. 
It  is  carried  down  and  across  the  palm  of  the  hand  about  the  middle  of 
the  metacarpal  bones  and  ends  one-half  inch  below  the  stjdoid.  process  of 
the   ulna.      The   incision   on   the    back   of   the   wrist    curves   slightly   upward 


340 


OPERATIVE   SURGERY 


].'ig.     351. A,    disarticulation     of    the     third,     fourth,    and     fifth     metacarpal     bones;     B,     disarticulation     of 

all  metacarpal  bones  except  the  thumb. 


Pig     352 A    and    A',    amputation    of    the    hand    at    wrist    joint    by    equal    flaps.      B,     disarticulation     of 

third  and  fourth  metacarpal  bones.     ' 


Tin:  rri'EU  extremities  341 

so  Hull  llu'  pnliiKir  ll;i|)  coNcrs  well  llic  wIidIc  ol'  Hie  slum]).  The  dorsal 
iiu'isioii  is  I'jirricd  down  lo  I  lie  lioiic  iiiid  llic  tissues  are  dissected  as  fai- 
ns till'  ,j.)iiit.  The  long  tendons  are  divided  either  at  the  extreme  level 
of  the  incision  to  allow  them  to  retract  or,  if  a  motor  stump  is  planned,  they 
are  made  lono>  and  tlie  extensor  tendons  are  united  to  the  flexor  tendons 
across  the  ends  of  the  bone  after  the  joint  has  been  divided.  After  complet- 
ing the  disarticulation  of  the  joint  the  palmar  flap  is  turned  back  and  sutured 
to  the  dorsal  flap.    Drainage  is  provided  for  the  first  forty-eight  hours. 

If  impossible  to  secure  a  long  palmar  flap  at  the  wrist  a  double  flap  can 
be  used,  making  the  palmar  flap  and  the  dorsal  flap  of  about  equal  length. 
Great  care  should  be  taken  to  see  that  the  flaps  are  not  too  narrow.  (Fig.  352.) 
Sometimes  flaps  may  be  secured  from  the  side,  either  from  the  radial  or  ulnar 
side,  depending  upon  the  emergency  of  the  situation. 

Amputation  of  the  forearm  can  usually  be  satisfactorily  done  either  by 
the  circular  method  or  by  an  anterior  and  posterior  flap,  as  has  been  de- 
scribed. In  the  lower  third  of  the  forearm  the  circular  or  cuff  method  is 
good  or  a  double  flap  may  be  used.  In  the  upper  two-thirds  of  the  forearm 
the  circular  method  or  equal  flaps  are  satisfactory.  The  muscle  can  best 
be  cut  in  tAvo  layers,  superficial  and  deep.  Particular  care  must  be  taken 
to  see  that  the  median,  radial,  ulnar,  and  interosseous  nerves  are  identified, 
injected  w^th  alcohol  and  divided  as  high  as  possible,  so  that  they  will  not 
form  attachments  to  the  scar  of  the  stump  (Fig.  353). 

A  motor  stump,  or  a  cineplastic,  amputation  may  be  done  through  the 
forearm.  Here  a  double  motor  stump  is  made.  The  circular  incision  through 
the  skin  and  subcutaneous  fascia  is  made  as  low  down  on  the  forearm  as 
possible,  and  the  muscles  and  tendons  are  divided  to  the  bone  at  a  level  with 
the  retracted  skin.  Vertical  incisions  are  made  on  the  radial  and  on  the  ulnar 
side  down  to  the  bone  extending  up  from  the  circular  skin  incision  about 
six  inches.  In  this  manner  an  anterior  and  a  posterior  flap  are  formed  and 
are  dissected  up  so  that  each  flap  contains  all  the  tendons,  muscles  and  other 
tissues  between  the  skin  and  the  bone.  The  radius  and  ulna  are  divided 
at  the  upper  end  of  the  vertical  incisions.  In  this  manner  one  flap  contains 
the  extensor  tendons  and  the  other  the  flexor  tendons.  The  skin  and  fascia  are 
freed  from  the  muscle  of  the  flap  for  about  half  the  length  of  the  flap  and 
the  tendons  in  each  flap  are  divided  into  two  groups.  Each  group  is  sewed 
together  so  as  to  make  a  loop.  The  skin  of  each  flap  is  then  sutured  over  the 
flap  to  cover  the  bundles  of  tendons,  and  a  longitudinal  incision  is  made  in 
the  skin  of  the  flap  opposite  the  loop  of  the  tendons.  A  second  incision 
is  made  in  the  folded  over  skin  opposite  the  first  incision.  These  button-hole 
incisions  are  about  one  inch  long. 

A  similar  procedure  is  carried  out  with  each  flap.  In  this  manner  the 
anterior  flap  contains  the  flexor  tendons  and  the  posterior  contains  the  ex- 
tensor tendons.  In  each  of  these  two  flaps  the  long  tendons,  which  have  been 
sewed  together  in  a  loop,  surround  a  perforation  that  is  made  in  the  skin 
covering  the  flaps.     A  rubber  tube  is  placed  through  the  perforation  in  the 


342 


OPERATIVE    SURGERY 


anterior  flap  and  another  rubber  tube  in  the  posterior  flap.  No  traction  is 
made  upon  these  tubes  for  about  ten  or  twelve  days  when  gradual  traction  is 
begun.  The  patient  can  voluntarily  move  the  anterior  or  flexor  flap  or  the 
posterior  or  extensor  flap.  An  apparatus  fitted  over  the  forearm  and  con- 
nected with  these  flaps  in  front  and  behind  can  be  worked  voluntarily  by 
cords  running  from  the  flaps  to  the  flngers  of  the  artiflcial  hand. 

A  motor  or  cineplastic  stump  can  also  be  constructed  by  having  tlie 
group  of  anterior  flexor  tendons  attached  to  a  piece  of  bone,  as  to  the  end 
of  the  radius,  and  the  posterior  or  extensor  tendons  to  the  end  of  the  ulna. 
About  two  inches  of  the  bone  is  resected,  just  proximal  to  the  end,  leaving  the 


y^ 


Fig.  353. — I^ines  of  incision  for  amputation  of  forearm;  A,  by  cuff  method;  B,  by  equal  flaps;   C,  by  oblique 

circular  method;   D,  by   circular   method. 

ends  of  the  radius  and  ulna  unconnected.  A  slight  constriction  is  placed 
on  the  stump  behind  the  ends  of  the  bones  and  when  healing  takes  place  a 
ring  is  fitted,  which  is  capable  of  transmitting  motion  to  an  appliance  that 
is  connected  with  it.  This  works  on  the  same  principle  as  the  perforated  cine- 
plastic  flap. 

If  there  is  infection  the  cineplastic  amputation  should  not  be  attempted, 
but  all  of  the  tendons  and  muscles  of  the  stump  should  be  saved  and  after 
healing  has  occurred  and  infection  has  been  overcome  the  cineplastic  ampu- 
tation may  be  done. 

Cineplastic   amputations   producing   a   motor   stump   have   been   used   in 


THE    ITPPEK    EXTREMITIES  343 

ll.ilv,  bill  \\\c  iiH'tliod  lias  iiol  hccii  widely  adopted.  It  ap])areiilly  lias  not 
been  sat  isfat-lory  in  Anieriea.  It  ixMinires  very  considerable  sacrifice  of  the 
bdiie  in  okKm-  to  produce  tlu'  motor  stuiiii)  and  consequently  greatly  shortens 
the  st  11111]).  The  llai)s  are  dil'tieult  to  ki'cp  in  good  condition,  but  the  most 
ini|)ortaiit  objection  seems  to  be  that  it  is  difficult  to  obtain  in  America  the 
proper  apparatus  to  be  applied  and,  of  course,  Avithout  the  proper  apparatus 
the  cineplastic  stump  is  of  no  more  value  than  the  simpler  amputation.  If 
attempted  in  amputation  above  the  elbow  the  same  principle  would  be  adopted 
as  in  the  forearm. 

In  any  amputation  about  the  arm  or  forearm  as  much  tissue  as  possible 
sliould  always  be  saved.  An  effort  should  be  made  to  provide  a  stump  as 
nearly  ideal  as  it  can  be  made.  This  means  that  the  scar  should  l)e  linear,  sliould 
not  be  adherent  to  the  bone,  and  should  not  have  too  much  redundant  tissue. 
In  amputation  about  the  hand  ever}'^  effort  must  be  made  to  preserve  as 
much  of  the  hand,  and  particularly  of  the  fingers,  as  possible.  To  leave  one 
finger,  however,  when  the  tendons  are  destroyed  is  doubtful  wisdom,  as  it 
becomes  ankylosed  and  painful  and  better  service  may  often  be  obtained  by 
providing  a  hook  or  some  similar  device  that  can  be  attached  to  the  end 
of  an  artificial  arm.  The  stump  of  the  forearm  is  valuable  for  leverage  and 
should  be  left  long  except  that,  when  the  bones  of  the  carpus  are  seriously 
injured,  it  may  be  better  to  amputate  at  the  wrist  joint  than  through  the 
carpus  or   at   the   carpometacarpal  junction. 

If  the  bones  in  the  stump  of  the  forearm  measure  less  than  three  inches 
from  the  tip  of  the  olecranon  it  will  be  difficult  or  impossible  to  adjust  a  satis- 
factory artificial  arm,  though  if  it  is  contemplated  not  to  use  an  artificial  arm  even 
so  short  a  stump  is  of  considerable  service.  The  possibility  of  the  use  of  an 
artificial  arm  must  always  be  borne  in  mind  when  amputating  in  the  arm 
or  forearm,  though  many  patients  do  not  wear  artificial  arms,  whereas  after 
amputation  in  the  lower  extremity  an  artificial  leg  is  always*  most  desirable. 
An  amputation  through  the  elbow  is  difficult  to  fit  with  an  artificial  arm,  so 
if  an  artificial  arm  is  contemplated  and  a  satisfactory  stump  cannot  be  se- 
cured, from  the  forearm,  it  will  be  better  to  amputate  about  one  inch  above 
the  condyles  of  the  humerus. 

In  amputation  of  the  forearm  the  stump  should  be  as  long  as  possible. 
The  anatomy  of  the  parts  must  be  borne  in  mind  as  in  operations  elsewhere. 
The  main  nerves  of  the  forearm,  which  are  the  median,  the  ulnar,  the  inter- 
osseous, and  the  radial,  should  be  identified  as  well  as  the  arteries.  The  re- 
lations of  these  structures  to  the  muscles  vary  at  different  levels  of  the 
forearm. 

Amputation  at  the  elbow  may  be  done  by  any  operation  that  permits  sat- 
isfactory covering  of  the  end  of  the  bone.  It  must  be  recalled  that  am- 
putation or  disarticulation  through  the  elbow  is  not  satisfactory  if  an  arti- 
ficial arm  is  to  be  worn,  and  also  that  the  end  of  the  humerus  requires  a 
laro-e  flap  of  skin  to  cover  it  satisfactorily.  The  anatomical  structures  of 
importance  about  the  elbow  are  important.    The  largest  artery  is  the  brachial. 


344 


OPERATIVE    SURGERY 


Avitli  the  superior  and  inferior  profunda,  and  the  anastomotica  magna.  The 
flaps  will  usually  contain  the  radial  with  its  recurrent  branch  and  the  ulnar 
with  its  recurrent  branches.  The  position  of  the  ulnar  nerve,  the  musculo- 
spiral,  and  the  median,  the  last  of  which  lies  internal  to  the  brachial  artery 
at  the  elbow  joint,  must  be  borne  in  mind. 

Probably  the  most  satisfactory  method  of  amputation  at  the  elbow  is 
the  elliptical,  or  oblique  circular,  method ;  though  a  long  posterior  flap  and 
a  short  anterior  flap  make  a  satisfactory  amputation  as  the  skin  on  the  back 
of  the  forearm  is  thicker  and  tougher  than  tlie  skin  on  the  front  of  the  fore- 
arm. The  necessities  of  the  occasion,  however,  ma}'  demand  a  longer  flap 
from  the  front  of  the  forearm  or  an  external  and  an  internal  flap. 


Fig.   354. — Lines   of  incision   for   amputation   at   elbow  by  posterior   elliptical   flap. 


If  the  amputation  is  to  be  done  by  the  elliptical  method,  this  is  begun  by 
marking  out  the  skin  flap  and  making  the  upper  limit  anteriorly  about  oppo- 
site the  condyles  (Fig.  354).  The  lower  limit  is  posterior  and  about  one  and 
one-half  diameters  of  the  arm  below  the  condyle,  that  is,  about  one-half  of 
the  circumference  of  the  arm.  The  flap  is  about  four  inches  long  in  the  av- 
erage case.  The  incision  is  begun  with  an  ordinary  scalpel  at  the  upper  limit 
with  the  .joint  flexed  at  a  right  angle  and  passes  down  the  inner  side  of  the 
joint  and  obliquely  down  to  the  lower  limit,  then  upward  on  the  outer  por- 
tion of  the  limb  to  the  point  of  beginning.  The  skin  and  fascia  are  cut  through 
and  when  retraction  has  occurred  the  muscles  are  divided  on  the  line  of  the 
retracted  flap.  The  posterior  muscles  are  dissected  free  from  the  bone  and 
when  the  dissection  has  reached  the  ligaments  of  the  joint  the  ligaments  are 


TilE    UPPER   EXTREMITIES 


345 


divided  and  left  atlarlird  to  llif  muscle.  Disarticulation  is  completed  by  an 
incision  in  front  and  llu>  posterior  muscle  flap  is  turned  forward  and  sutured 
over  the  articular  surface.  The  skin  flap  is  then  separately  sutured.  The 
convex  lower  end  of  the  flap  is  fitted  into  concave  upper  part  of  the  ellipse. 
If  the  disarticulation  is  done  hy  a  long  posterior  and  a  short  anterior  flap  the 
incisions  are  marked  out  beginning  about  an  inch  below  the  condyles.  The 
posterior  flap  is  shaped  by  carrying  the  incision  down  and  then  backward 
across  the  back  of  the  forearm.  .This  joins  a  similar  incision  on  the  other 
side.  The  anterior  flap  is  about  one-half  the  length  of  the  posterior  flap.  The 
length  of  both  flaps  is  equal  to  about  one-half  the  circumference  of  the  arm 
at  the  condyles.  The  fascia  is  incised  and  allowed  to  retract  and  the  muscles 
are  cut  on  the  level  of  the  retracted  flap.     They  are  dissected  from  the  bone 


Fig.    355.— Lines    of    incision    for    amputation    of    the    arm:    A,    by    lateral    flaps;    B,    by    long    external    Hap; 

C,  by  circular  method. 

up  to  the  ligaments  of  the  joint  and  the  ligaments  are  divided  as  in  am- 
putation by  an  ellipse.  As  much  of  the  ligaments  as  possible  is  left  attached 
to  the  muscle  flap.  This  is  a  rule  in  amputation  at  any  joint.  The  ligaments 
of  the  head  of  the  radius  are  divided  behind  as  the  elbow  is  flexed,  and  in  this 
manner  the  joint  is  opened.  The  capsule  of  the  joint  is  divided  around  the 
olecranon  and  the  elbow  is  then  extended  and  division  completed  anteriorly. 
After  tying  the  vessels  the  muscles  are  sutured  over  the  joint  and  the  skin 
is  closed  as  in  amputation  by  the  ellipse. 

Amputation  o'f  the  arm  may  be  done  at  any  level  but  if  an  artificial 
arm  is  to  be  employed  the  stump  should  be  not  longer  than  results  from 
the  section  of  bone  about  one  inch  above  the  condyles   (Fig.  355).     Every 


346  OPERATIVE    SI'RGERY 

inch  of  good  stump  that  can  be  saved  above  this  adds  to  the  strength  of  the 
stump  and  makes  the  artificial  arm  more  efficient.  The  anatomy  of  the  arm 
must  be  thoroughly  considered  before  undertaking  an  amputation.  At  the 
upper  part  of  the  arm  all  the  important  cords  and  vessels  are  on  the  inner 
portion  of  the  arm.  The  musculospiral  nerve  about  the  middle  of  the  arm 
is  closely  connected  with  the  humerus,  and  it  is  particularly  important  to 
guard  against  the  possibility  of  the  stump  of  this  nerve  being  involved  in 
the  healing  of  the  bone  after  amputation.  This  nerve  should  be  identified, 
pulled  doAvn,  injected  with  alcohol,  and  divided  so  that  it  may  retract.  This 
treatment,  of  course,  should  be  given  all  nerves  that  can  be  recognized  but 
it  is  particularly  important  in  the  musculospiral. 

Amputation  in  the  lower  third  of  the  arm  may  be  done  satisfactorily 
Avith  the  circular  method,  or  any  form  or  shape  of  flap  can  be  used  that 
suits  the  emergencies  of  the  situation.  An  external  and  internal  flap  give 
better  drainage.  If  the  circular  method  is  used  it  is  done  as  recommended 
for  other  circular  methods  and  the  wound  is  sutured  anterior-posteriorly 
in  order  to  secure  satisfactory  drainage.  The  modified  circular  method  with 
short  flaps  or  a  short  anterior  and  a  long  posterior  flap  may  be  used.  If 
flaps  are  used  they  are  so  fashioned  as  to  provide  satisfactory  covering  for 
the  stump.  All  the  nerves  must  be  treated  as  mentioned  for  the  musculo- 
spiral. 

Amputation  of  the  middle  third  of  the  arm  may  be  done  with  flaps  that 
are  equal  or  unequal.  Usually  a  long  anterior  and  a  short  posterior  flap  are 
used.  The  flaps  should  be  equal  in  length  to  one-half  the  circumference  of 
the  limb  and  the  anterior  flap  is  twice  the  length  of  the  posterior.  The  bra- 
chial artery  should  lie  in  the  anterior  flap.  It  is  highly  important  that  the 
nerves  be  identified  and  properly  treated. 

Amputation  of  the  upper  third  of  the  arm  is  best  done  by  a  single  exter- 
nal flap,  though  anterior  and  posterior  flaps  may  be  used.  If  the  external 
flap  method  is  adopted  the  vertical  incisions  are  begun  at  opposite  points, 
anterior  and  posterior,  and  are  about  an  inch  below  the  point  of  division  of 
the  bone.  These  incisions  pass  downward  and  curve  to  a  point  on  the  outer 
side  of  the  arm  so  that  the  flap  is  equal  in  length  to  the  diameter  of  the 
limb,  which  is  a  third  of  the  circumference.  An  inner  incision  connecting 
the  upper  ends  of  the  two  vertical  incisions  is  made  and  passes  obliquely 
downward  and  inward  on  the  portion  of  the  arm  next  to  the  thorax.  It  is 
best  to  save  the  tendon  of  the  major  pectoralis  muscle.  If  the  bone  is  to  be 
divided  above  its  insertion,  the  periosteum  with  the  insertion  of  this  tendon 
is  stripped  up  and  left  in  the  flap  and  is  sutured  to  structures  on  the 
outer  or  front  side  of  the  stump  of  the  bone.  The  tendons  of  the  latissimus 
dorsi  and  the  teres  major  muscles  are  also  preserved  if  possible.  The  cir- 
cumflex nerve  and  the  posterior  circumflex  artery  are  kept  from  injury 
by  making  the  incision  along  the  thorax  side  of  the  arm  low  down.  After 
the  muscles  have  been  divided  to  the  bone  the  outer  flap  is  retracted  and  then 
the  soft  parts  of  the  inner  portion  of  the  arm  are  also  retracted  to  expose  the 


THE    UPPER    EXTREMITIES 


347 


bone.     A  iiiallruMc  rcl  ractor  is  jilacccl  internally  in  order  to  protect  the  ves- 
sels ■while  the  bone  is  being  sawed. 

Amputation  or  disarticulation  at  the  shoulder  joint  can  be  done  by  the 
external  racket  incision  of  Larrey,  by  the  anterior  racket  incision  of  Spence, 
or  by  the  U-shaped  tiap.  The  great  problem  in  all  of  these  operations  is  the 
control  of  hemorrhage.  The  ditTiculty  ^vith  a  tournifiuet  lies  in  the  fact  that 
a  tourniquet  will  slip  after  disarticulation  at  the  shoulder  by  any  operation 
unless  it  is  fastened  by  some   special  method.     Sometimes  preliminary   liga- 


Fig.  356. — W'yeth's  method  of  hemostasis  for  amputation  at  shoulder. 

tion  of  the  subclavian  artery  is  advisable  if  the  amputation  is  done  because  of 
a  tumor  that  encroaches  upon  the  joint  and  makes  the  application  of  a 
tourniquet  so  near  the  lines  of  incision  that  too  small  a  margin  of  healthy 
tissue  will  be  left.  If  the  metal  pins  of  Wyeth  are  used  to  hold  the  tour- 
niquet in  position  the  anterior  piu  enters  at  the  middle  of  the  lower  margin 
of  the  anterior  axillary  fold  and  emerges  about  an  inch  internal  to  the  tip 
of  the  acromion  process.  The  posterior  pin  enters  the  corresponding  point 
on  the  posterior  axillary  fold  and  emerges  posterior  to  the  first  pin  and  about 
the  same  distance  internal  to  the  tip  of  the  acromion  process.     A  large  soft 


348 


OPERATIVE    SURGERY 


rubber  tube  is  wrapped  arouud  the  shoulder  internal  to  the  pins  after  the 
tips  of  the  pins  have  been  protected  by  cork  to  prevent  injury  to  the  oper- 
ator's hands.  The  tube  is  wrapped  around  tightly  four  or  five  times  and 
securely  fastened  by  tying  the  ends  with  a  bandage,  and  also  by  a  stout 
clamp.  The  ends  are  placed  posteriorly  so  they  will  be  out  of  the  way  during 
the  manipulation  of  securing  the  vessels  and  severing  the  nerves,  which 
are  at  the  anterior  and  inner  portion  of  the  upper  arm  (Fig.  356). 

If  the  external  racket  method  is  to  be  used  the  incision  begins  just  be- 
low and  in  front  of  the  acromion  process  and  is  carried  down  vertically  on 
the  outer  surface  of  the  arm  for  about  four  inches.  From  the  center  of 
this  incision  an  oval  incision  is  begun  which  is  carried  around  the  arm  down- 
ward and  then  upward  in  such  a  manner  that  the  lowest  point  of  the  oval 


Fig.   357. — Lines  of  incision   for  amputation   of  shoulder  by  anterior   racket  method   of   Spence. 

incision  is  on  a  level  with  the  lowest  end  of  the  vertical  incision.  The  oval 
incision  is  carried  only  through  the  skin  and  subcutaneous  tissue  at  first. 
The  anterior  structures  are  then  divided  down  to  the  bone  and  after  this  the 
posterior  structures.  The  capsule  is  cut  over  the  head  of  the  bone  and  the 
arm  rotated  outward  when  the  tendon  of  the  subscapular  muscle  is  cut.  Af- 
ter this  the  arm  is  rotated  inward  and  the  supraspinatus,  the  infraspinatus 
and  the  teres  minor  muscles  are  divided.  The  rest  of  the  capsule  of  the  joint 
and  the  ligaments  are  divided,  saving  as  much  of  these  structures  for  the  flap 
as  possible.  The  axillary  artery  is  doubly  ligated  with  catgut  and  the  nerves 
are  treated  in  the  usual  manner,  being  injected  with  alcohol.  All  vessels  are 
clamped  and  tied  and  the  tourniquet  is  gradually  loosened  to  see  if  any  bleed- 
ing vessels  have  escaped.  The  muscles  and  fascia  are  sutured  together  and 
the  skin  is  closed  in  the  usual  manner. 

The   anterior  racket   incision    (Fig.   357)    is   done   by   a   vertical   incision 


THE   UPPER   EXTREMITIES  349 

■\vhicli  begins  at  1lu'  \v\v\  of  llie  upper  portion  of  the  head  of  the  liunierus 
betAveen  the  coraeo'ul  and  acromion  processes  and  passes  down  through  the  del- 
toid and  nuijor  pectoral  muscle  to  the  insertion  of  the  major  pectoral  mus- 
ch',  which  is  divided.  Here  the  incision  branches  and  one  passes  downward 
and  inward  and  the  other  downward  and  outward,  forming  an  oblique 
incision  and  surrounding  the  arm  about  on  a  level  with  the  insertion  of 
the  deltoid  muscle.  The  vertical  part  of  the  incision  exposes  the  joint  and 
the  bone.  The  muscles  are  cut  on  a  level  with  the  retracted  skin  and  fascia, 
dissecting  up  the  inner  portion  of  the  flap  toward  the  axilla  first.  The  outer 
portion  of  the  incision,  which  divides  the  deltoid  muscle  just  above  its  in- 
sertion, is  then  carried  down  to  the  bone,  taking  care  to  avoid  the  circum- 
flex nerve  to  the  deltoid,  by  making  the  outer  limb  of  the  incision  as  Ioav  as 
the  insertion  of  the  deltoid  muscle.  This  incision  is  then  carried  down  to 
the  bone  and  the  muscles  are  separated  from  the  bone  by  periosteal  elevators. 
Much  of  this  can  be  done  through  the  vertical  incision  by  rotating  the  arm 
first  inward  and  then  outward.  The  muscles  inserted  into  the  head  of  the 
humerus  are  divided  and  as  much  of  the  capsule  of  the  joint  is  preserved  as 
possible.  After  securing  the  vessels  and  treating  the  nerves  the  stumps 
of  the  muscles  are  sutured  together  to  protect  the  acromion  process  and  the 
glenoid  cavity. 

Amputation  through  the  shoulder  joint  may  also  be  done  by  inner  or 
outer  flaps  or  by  other  combinations  that  may  appear  advisable  under  the 
circumstances.  Crile  makes  an  incision  along  the  outer  margin  of  the  sterno- 
mastoid  just  above  the  clavicle,  divides  the  deep  fascia,  retracts  the  omohyoid 
downward  and  the  trapezius  muscle  backward,  and  exposes  the  trunks  of 
the  brachial  plexius  and  also  the  subclavian  artery.  The  trunks  of  the  brachial 
plexus  are  injected  with  novocaine  or  with  cocaine.  A  clamp  whose 
blades  are  protected  with  rubber  is  applied  to  the  subclavian  artery.  Ampu- 
tation is  then  carried  out  without  a  tourniquet,  according  to  any  of  the  methods 
that  may  seem  desirable. 

Amputation  of  the  complete  upper  extremity,  or  interscapulothoracic 
amputation,  is  occasionally  indicated.  The  method  of  LeConte  is  satisfac- 
tory. The  incision  begins  at  the  inner  end  of  the  clavicle  and  is  carried 
along  the  bone  to  its  middle,  then  curves  downward  to  the  anterior  axillary 
fold.  The  skin  and  superficial  fascia  are  dissected  exposing  the  inner  two- 
thirds  of  the  clavicle.  The  clavicle  is  disjointed  from  its  attachm^ent  to  the 
sternum  and  the  sternomastoid  muscle  is  divided  Avhere  it  is  inserted  into 
this  bone.  The  clavicular  portion  of  the  pectoralis  major  is  separated  bluntly 
from  the  costal  portion  of  the  muscle  as  far  as  the  anterior  axillary  fold.  The 
clavicle  is  pulled  upward  and  forward  and  the  subclavius  muscle,  which  is  put 
on  a  stretch,  is  divided  at  the  first  rib.  The  pectoralis  minor  is  next  di- 
vided and  its  outer  portion  reflected  up  with,  the  clavicle.  The  axilla  and 
its  vessels  are  fully  exposed.  The  sheath  of  the  vessels  is  opened,  the  vein 
separated  from  the  artery,  and  two  ligatures  are  passed  around  the  artery. 
The  arm  is  then  held  up  to  empty  the  blood  into  the  veins  as  much  as  possi- 


350  OPERATIVE    ST'RGERY 

ble  and  two  ligatures  are  placed  on  the  vein.  If  the  cephalic  vein  enters  the 
axillary  vein  above  the  point  of  ligature  it  will  also  require  a  ligature.  The 
vessels  and  the  brachial  plexus  are  divided.  The  costal  portion  of  the  pecto 
ralis  major  is  severed,  which  completes  the  division  of  the  anterior  attach- 
ments of  the  arm.  The  posterior  incision  is  then  carried  from  some  point 
on  the  anterior  incision,  as  near  the  tumor  as  it  is  thought  safe  to  go,  back- 
w^ard  and  downward  to  the  lower  angle  of  the  scapula  and  then  to  the  pos- 
terior axillary  fold.  The  skin  and  fascia  are  dissected  for  a  short  distance, 
the  trapezius  muscle  is  divided,  and  the  transversalis  coli  and  the  posterior 
scapular  arteries  are  secured  and  divided.  "  The  muscles  attached  to  the  inner 
border  of  the  scapula  are  divided  close  to  the  bone,  the  seratus  magnus  mus- 
cle is  severed,  and  the  latissimus  dorsi  is  divided  at  the  posterior  axillary 
fold.  The  arm  is  now  held  to  the  body  only  by  the  skin  of  the  axilla.  If 
there  is  enough  flap  to  cover  the  wound  the  anterior  and  posterior  incisions 
may  be  sutured  over  the  axilla,  but  if  more  skin  is  needed  a  flap  should  be 
fashioned  from  the  under  surface  of  the  arm  with  its  base  at  the  axilla 
before  completing  the  amputation.  The  skin  and  the  superficial  fascia  are  united 
in  the  usual  manner  and  a  drain  is  inserted  at  the  lowest  angle.  No  effort 
is  made  to  suture  the  muscles. 

Crile  advises  dividing  the  clavicle  and  resecting  the  inner  half  of  the 
bone  to  expose  the  subclavian  vessels  and  the  brachial  plexus.  He  then 
injects  the  brachial  plexus  with  cocaine,  or  novocaine,  ligates  the  subclavian 
artery  and  then  the  subclavian  vein.  The  rest  of  the  operation  may  be  com- 
pleted according  to  the  method  of  LeConte. 

The  chief  advantage  of  the  method  of  LeConte  is  in  exposing  the  subcla- 
vian artery  and  vein  so  that  the  artery  can  be  readily  tied  before  the  vein  is 
divided.     In  this  manner  much  loss  of  blood  is  prevented. 

EXCISIONS 

Excision  of  the  wrist  joint  may  be  partial  or  complete.  In  partial  ex- 
cision the  region  to  be  excised  is  exposed  by  an  incision  tliat  injures  the  ten- 
dons, vessels,  and  nerves  as  little  as  possible.  In  complete  excision  the  oper- 
ation may  be  done  by  a  single  dorsal  incision,  by  two  dorsal  incisions,  or  by 
two  bilateral  incisions.  The  styloid  processes  of  the  radius  and  ulna  and  the 
base  of  the  second  metacarpal  bone  are  identified.  When  a  single  dorsal  in- 
cision is  used  it  is  placed  along  the  outer  border  of  the  extensor  indicis 
tendon.  The  incision  is  about  four  inches  long  and  begins  over  the  lower 
end  of  the  radius  and  ends  about  the  middle  of  the  second  metacarpal  bone. 
The  dorsal  structures  are  freed  while  extending  the  wrist  to  relax  the  exten- 
sor tendons.  The  bones  of  the  wrist  may  be  excised  subperiosteally  through 
this  incision  by  making  strong  retraction.  AVhen  the  structures  are  large 
and  the  tendons  strong  two  dorsal  incisions  are  more  satisfactory.  Here  a 
radial  incision  starts  over  the  lower  end  of  the  radius  about  half  way  between 
the  styloid  process  of  the  ulna  and  the  styloid  process  of  the  radius.     The 


THE    UPPER    EXTREMITIES  351 

iiu'isioii  is  t'jirrit'd  ()l»li(|ii('ly  dowiiw;!  fcl  lo  1lu'  oiifci-  side  of  the  luiddlc  of  the 
second  metfu-arpal  l)oiu'.  Tlu'  upper  end  of  the  ineision  may  be  proloii<;'od 
on  the  forearm  if  it  facilitates  the  operation.  The  tendon  of  the  extensor 
indicis  is  retracted  outward,  thus  exposing  the  metacarpal  bones.  The  dorsal 
branch  of  the  radial  nerve  must  be  protected.  The  posterior  annular  liga- 
ment is  divided  and  the  wrist  joint  is  opened.  The  second  incision  begins 
about  one  and  one-quarter  inches  above  the  tip  of  the  styloid  process  of  the 
ulna  and  goes  downward  to  the  base  of  the  fifth  metacarpal  bone.  It  is  on  the 
outer  side  of  the  tendon  of  the  extensor  carpi  ulnaris  and  exposes  the  ulna 
and  the  unciform  bone.  The  dorsal  branch  of  the  ulnar  nerve  to  the  little 
finger  must  be  avoided.  The  carpus  is  removed  by  stripping  the  bones  from 
their  ligaments  and  periosteum  and  removing  them  with  forceps  or  a  curet. 
The  ends  of  the  radius  and  ulna  can  be  removed  by  pushing  them  through 
the  wound,  stripping  back  the  periosteum,  and  sawing  off  the  diseased  portion. 
Drainage  tubes  are  inserted  and  the  hand  is  put  in  a  splint. 

Bilateral  incisions  are  sometimes  used  for  excision  of  the  wrist  joint. 
Here  the  outer  incision  begins  at  the  middle  of  the  loAver  end  of  the  radius 
about  on  a  level  with  the  base  of  its  styloid  process.  The  incision  goes  down- 
ward and  outward,  parallel  with  the  tendon  of  the  extensor  longus  pollicis 
to  the  inner  side  of  the  first  carpometacarpal  articulation.  From  this  point 
it  is  carried  down  the  outer  side  of  the  second  metacarpal  bone  to  the  middle 
of  this  bone.  This  incision  is  four  inches  long.  The  radial  artery  should  be 
avoided.  The  incision  will  divide  the  insertion  of  the  tendon  of  the  extensor 
carpi  radialis  muscle  but  no  other  tendons.  The  soft  tissues  on  the  ulnar 
side  of  the  incision  are  dissected  while  the  wrist  is  extended.  The  trapezium 
bone  is  not  removed  until  last  and  should  be  left  unless  its  removal  is  neces- 
sary. The  second  lateral  incision,  about  two  inches  long,  begins  at  the  loAver 
front  end  of  the  ulna  and  goes  down  between  the  bone  and  the  tendon  of  the 
flexor  carpi  ulnaris  as  far  as  the  middle  of  the  fifth  metacarpal  bone  on  its 
palmar  surface.  The  inner  side  of  the  wound  is  retracted  and  the  insertion 
of  the  tendon  of  the  extensor  carpi  ulnaris  is  cut.  The  posterior  soft  tissues 
are  dissected  from  the  bone  while  the  wrist  is  strongly  extended.  The  pos- 
terior ligaments  are  divided,  though  the  connection  of  the  tendons  with  the 
radius  is  left  (Fig.  358). 

In  excisions  by  any  method  it  is  wise  to  remove  diseased  bone  and  leave 
healthy  bone  wherever  possible  even  though  a  typical  operation  cannot  be 
done. 

Excision  of  the  elbow  may  be  performed  for  active  disease  or  for  anky- 
losis. In  the  presence  of  active  disease  the  pathology  is  removed  as  thoroughly 
as  seems  necessary.  When  the  operation  is  for  ankylosis  a  more  typical  pro- 
cedure can  be  followed.  One  type  of  operation,  however,  cannot  well  meet 
all  indications.  By  whatever  method  of  approach  the  operation  is  done,  an 
effort  should  be  made  to  remove  no  more  bone  than  is  necessary  and  it  must 
always  be  borne  in  mind  that  a  stiff  elbow  joint  ankylosed  at  an  angle  is  pref- 
erable to  a  flail  joint  (Fig.  359). 


352 


OPERATIVE   SURGERY 


In  the  typical  operation  the  humerus  is  sawed  through  at  its  epicondyle, 
the  ulna  at  the  base  of  the  coronoid  process,  and  the  radius  at  its  neck.  Some- 
times more  bone  than  this  must  be  sacrificed.  Sometimes  much  of  the  ole- 
cranon can  be  saved  and  this  is  always  desirable,  as  it  contains  the  insertion 
of  the  triceps  muscle.  The  insertion  of  the  brachialis  anticus  muscle  in  the 
ulna  and  the  biceps  in  the  radius  should  be  preserved  if  possible.  The  pos- 
terior part  of  the  joint  is  subcutaneous.  All  of  the  important  vessels  and 
nerves  lie  in  front  of  the  joint,  except  the  ulnar  nerve,  which  must  be 
carefully  protected,  particularly  that  portion  which  lies  behind  the  inner  con- 
dyle of  the  humerus  and  along  the  inner  side  of  the  olecranon. 

Excision  may  be  done  by  a  long  posterior  incision,  by  a  lateral  incision 
on  the  radial  side,  or  by  a  right-angle  incision.  After  the  operation  the  arm 
is  put  in  a  splint  with  the  elbow  slightly  flexed.  Extension  can  be  placed 
upon   the  forearm  by  boards  in  a  plaster  of  Paris   case.     Adhesive  plaster 


Fig.  358. — Lines  of  incision  for  excision  of 
the  wrist:  A  and  A',  two  dorsal  incisions  (Oilier); 
B,  single  dorsal  incision  of  Boeckel;  C  and  C 
bilateral   incisions   of   leister. 


Fig.  359. — Eines  of  incision  for  excision  of 
elbow:  A  and  A',  long  external  and  short  internal 
incisions;    B,   a    right    angle    incision. 


strips  are  first  applied  to  the  forearm  in  someAvhat  the  same  manner  as  is  used 
on  the  leg  in  Buck's  extension.  These  are  connected  by  elastic  tubes  to  a 
cross  piece  over  the  ends  of  the  boards  as  they  protrude  beyond  the  hand. 
This  apparatus  is  removed  at  the  end  of  two  Aveeks  and  passive  motion 
is  begun  (p.  167). 

When  the  radial,  or  bayonet  incision  of  Oilier,  is  made  the  upper  arm 
is  placed  in  a  vertical  position  with  the  forearm  slightly  flexed.  The  incis- 
ion begins  about  two  inches  above  the  upper  portion  of  the  olecranon  in  the 
space  between  the  supinator  longus  and  the  triceps  about  one  and  one- 
quarter  inches  above  the  external  epicondjde.  The  incision  is  carried  down- 
v^^ard  parallel  with  the  humerus  to  the  epicondyle  and  then  downward  and  in- 
ward to  about  the  middle  of  the  outer  side  of  the  olecranon.  From  this  point 
it  goes  over  the  back  of  the  olecranon  and  downward  for  about  two  inches. 


THE    UPPER    EXTREMITIES  353 

Oil  JU'eoiiiit  of  its  sliiipi'  it  is  ol'ten  callcil  the  hjiyoiiet  incision.  The  ti'ieeps 
on  tlu-  inner  side  is  sepai'atecl  from  the  nuisek's  on  its  outer  side  and  the 
eapside  of  the  joint  is  exposed  and  opened.  The  periosteum  and  capsular 
ligaments  are  divided  at  the  outer  edge  of  the  articular  surface  and  the  at- 
tachiiieiits  of  the  muscles  are  raised  with  a  periosteal  elevator.  The  perios- 
teum of  the  ulna  with  the  tendon  of  the  triceps  is  raised  from  the  other 
edge  of  the  articular  surface.  The  external  condyle  of  the  humerus  is  de- 
nuded and  the  periosteum  and  muscular  and  ligamentous  attachments  are 
raised.  The  elbow  joint  is  flexed  and  the  lower  end  of  the  humerus  protrudes  into 
the  wound.  The  periosteum  is  completely  separated  and  the  lower  end  of  the 
bone  is  sawed  off.     The  head  of  the  radius  and  the  ulna  are  also  removed. 

The  posterior  median  incision  has  been  a  very  popular  one  for  excision 
of  the  elbow  joint.  It  is  about  four  inches  long  and.  is  in  the  direction  of 
the  long  axis  of  the  forearm.  It  begins  two  inches  below  the  tip  of  the 
olecranon  ijroeess,  passes  over  the  posterior  border  of  the  ulna  upward  and 
across  the  center  of  the  olecranon,  splits  the  triceps  tendon  and  is  carried 
down  to  the  bone.  The  joint  is  opened  and  the  parts  are  retracted,  taking  par- 
ticular care  to  protect  the  ulnar  nerve  on  the  inner  side  of  the  olecranon  and 
ulna.  The  periosteum  is  divided  over  the  humerus  and  stripped  up,  keep- 
ing close  to  the  bone.  The  ligaments  are  raised  in  the  same  manner. 
The  tissues  on  the  outer  side  are  also  separated  from  the  bone  until  the 
outer  condyle  is  reached.  The  posterior  interosseous  nerve  must  be  avoided 
in  this  region.  The  joint  is  strongly  flexed  and  the  lower  end  of  the  humerus 
protrudes  through  the  wound.    The  bone  is  sawed  in  the  usual  manner. 

Excision  by  a  right  angle  incision  is  done  by  beginning  a  longitudinal 
incision  three  inches  long  on  the  outer  side  of  the  joint  about  one  and  one- 
half  inches  above  the  tip  of  the  olecranon.  This  is  carried  doAvn  behind 
the  outer  condyle  at  a  point  just  behind  the  neck  of  the  radius.  A  second 
incision  is  carried  inward  at  a  right  angle  and  crosses  back  of  the  ulna.  This 
triangular  flap  with  the  periosteum  of  the  ulna  is  dissected,  the  external  liga- 
ments are  divided,  and  the  head  of  the  radius  is  removed.  Then  the  ulna  is 
exposed  and  sawed  across  and  the  humerus  finally  is  dislocated  into  the 
wound. 

After  any  of  these  operations,  muscles  or  fascia  may  be  interposed  be- 
tween the  ends  of  the  bones.  A  flap  of  fascia  or  muscle  from  the  brachialis 
anticus  or  from  the  anconeus  may  be  taken.  A  strip  of  fascia  lata  from 
the  leg  may  also  be  utilized.  This  is  fitted  over  the  lower  end  of  .the  humerus 
as  a  hood  or  cap  with  the  fatty  surface  toward  the  joint. 

In  any  excision  of  the  elbow  enough  bone  should  be  removed  to  permit  the 
hand  of  that  side  readily  to  be  carried  to  the  opposite  shoulder  after  the 
interposition  of  fascia. 

Excision  of  the  shoulder  joint  usually  requires  the  removal  only  of  the 
head  of  the  humerus,  though  sometimes  it  may  be  necessary  to  remove  the 
glenoid  cavity  also.  The  excision  may  be  done  through  the  anterior  incision 
of  Oilier,  through  the  vertical  incision  of  Langenbeck,  or  through  the  curved 


354 


OPERATIVE   SURGERY 


flap  incision  of  Senn.     (Fig.  .360.)     It  may  also  be  done  through  a  po.sterior 
approach,  according  to  the  method  of  Kocher. 

The  anterior  incision  is  about  four  inches  long  and  begins  at  the  outer 
side  of  the  tip  of  the  eoracoid  process  and  passes  downward  and  slightly 
outward  along  the  anterior  margin  of  the  deltoid  muscle.  The  capsular  liga- 
ment is  opened  to  the  outer  side  of  the  tendon  of  the  long  head  of  the  biceps. 
The  periosteum  and  the  capsular  ligaments  are  raised  from  the  bone  with  a 
periosteal  elevator  as  far  outward  as  possible  while  the  arm  is  rotated  in- 
ward. The  insertion  of  the  muscles  into  the  greater  tuberosity  is  raised 
along  with  the  periosteum.  This  may  be  done  by  a  periosteal  elevator  or 
with  a  chisel  if  the  condition  of  the  bone  permits.     The  tendon  of  the  biceps 


Fig.    360. — Ivines    of    incision    for    excision    of   the    shoulder    joint;    A,    curved    incision    of    Senn; 
B,   anterior  incision  of   Oilier;    C,  vertical  incision    of  Langenbeck. 

is  retracted  outward,  and  the  periosteum  is  elevated  toAvard  the  axilla.  The 
head  of  the  humerus  is  dislocated  through  the  wound,  the  periosteum  of 
the  posterior  surface  is  completely  elevated  and  the  head  of  the  bone  is 
saw^ecl  off.    Drainage  is  best  made  by  a  posterior  stab  wound. 

In  the  vertical  incision  of  Langenbeck  the  arm  is  rotated  inward  and  the 
incision  begins  at  the  anterior  border  of  the  acromion  process  and  goes  down 
about  four  inches  in  the  line  of  the  bicipital  groove.  The  incision  splits  the 
deltoid  muscle  to  the  tendon  of  the  biceps.  The  sheath  of  this  tendon  is 
divided,  the  tendon  retracted,  and  the  joint  opened  through  the  posterior 
portion  of  the  sheath.  The  periosteum  and  capsular  ligament  of  the  .joint  are  ele- 
vated while  first  rotating  the  arm  outward  and  then  inward.  The  bone  is 
removed  as  in  the  previous  operation.  This  operation  has  not  the  advantages 
of  the  preceding  one  because  the  incision  is  deeper  and  some  of  the  nerve 
supply  to  the  deltoid  is  destroyed. 

Senn  practiced  approach  to  the  shoulder  joint  by  raising  a  large  U-shaped 


THE    UPPER    EXTREMITIES  355 

Hap  \vitli  its  base  over  llie  shoulder  joint  and  eoiisisliiig  largely  of  the  deltoid 
muscle.  This  gi\es  an  exetdleiit  exposure  hut  divides  the  deltoid  and  makes 
an  extensive  Avound. 

Excision  of  the  shoulder  joint  can  be  done  posteriorly  by  the  method 
of  Kocher.  This  incision  begins  at  the  acromioclavicular  joint,  goes  backward 
along  the  acromion  and  spine  of  the  scapula,  dividing  the  trapezius  muscle. 
From  about  the  middle  of  the  spine  of  the  scapula  the  incision  is  carried 
doAvnward  toward  the  posterior  fold  of  the  axilla  ending  about  one  and  a 
half  inches  from  the  lower  border  of  this  fold.  The  infraspinatus  and 
supraspinatus  muscles  are  separated  from  the  acromion  and  the  acromion  proc- 
ess is  divided  with  a  saw  or  chisel  about  where  it  joins  the  spine  of  the  scapula. 
Holes  are  drilled  in  the  bone  for  future  suturing  before  it  is  divided.  The 
acromion  Avith  the  deltoid  muscle  attached  is  retracted  over  the  head  of  the 
humerus.     The  joint  is  opened  along  the  line  of  the  bicipital  tendon,  which 


Fig.   361. — Lines  of  incision  for  removal  of  diamond-shaped  area  at   elbow. 

is  retracted  forward  as  the  external  rotators  are  retracted  backward.  The 
head  of  the  bone  is  thus  readily  exposed  and  when  the  operation  is  com- 
pleted the  acromion  is  sutured  to  the  spinous  process  of  the  scapula. 

ARTHRODESIS  OF  THE  ELBOW 

The  operation  for  immobilizing  the  joints,  arthrodesis,  is  but  seldom  indi- 
cated in  the  joints  of  the  upper  extremity.  Occasionally  it  is  needed  to  fix  the 
elbow  joint.  This  is  best  done  by  the  procedure  of  Sir  Robert  Jones.  A  diamond- 
shaped  area  of  skin  is  excised  (Fig.  361).  The  upjDcr  extremity  of  the  diamond- 
shaped  incision  is  at  the  junction  of  the  middle  and  lower  thirds  on  the  an- 
terior surface  of  the  arm.  The  lower  extremity  of  the  incision  is  at  the 
junction  of  the  middle  and  upper  thirds  of  the  anterior  surface  of  the  forearm. 
The  lateral  angles  are"  in  front  of  the  condyles  of  the  humerus.  The  area 
of   the   skin  surrounded  by  these   incisions   is   excised   down   to   the   fascia. 


356 


OPERATIVE    SURGERY 


The  arm  is  flexed  and  the  upper  extremity  of  the  incision  on  the  arm  is  su- 
tured to  the  lower  extremity  on  the  forearm.  In  tliis  manner  the  arm  is  flexed 
and  kept  in  this  position  without  interfering  with  the  bone. 

INFECTION  OF  THE  HAND 

Infections  of  the  hand  and  fingers  are  common.  Incisions  for  infection 
should  he  made  down  to  and  including  the  infected  tissue,  but  preferably 
the  periosteum  and  bone  should  not  be  incised  unless  they  have  become  in- 
volved. If  infection  is  superficial  to  the  bone  and  an  incision  is  made  through 
it  to  the  bone,  infection  may  thus  be  carried  to  the  bone.  The  incision 
is  made  by  blocking  the  nerves  on  the  proximal  side  of  the  infection  well 
out  of  the  region  of  the  inflammation,  or  it  may  be  done  under  light  gen- 
eral anesthesia,  as  nitrous  oxicl  anesthesia.  The  incision  should  be  suffi- 
ciently ample  to  evacuate  the  inflammatory  products,  but  it  is  best  not  to 


Fig.    362. — ^lethod    of    Dorrancc    for    incision    of    felon    and    jjlacing    of    drainage. 

carry  it  out  of  the  infected  region,  for  if  this  is  done  the  natural  defenses 
that  haA^e  been  formed  around  the  infected  focus  as  barriers  of  lymph  and 
leukocytic  inflltration  will  be  broken  through  by  the  knife.  The  bacteria 
will  then  have  free  access  to  unprotected  tissue. 

The  incision  should  preferably  be  made  on  the  side  of  the  finger  instead 
of  directly  in  the  palmar  surface  so  as  to  interfere  as  little  as  possible  with 
the  action  of  the  tendons.  It  should  be  in  the  long  axis  of  the  finger  and  should 
not  disturb  the  tactile  area. 

For  infection  of  the  tip  of  the  finger,  Dorrance  makes  an  incision  parallel 
to  the  nail  and  a  short  distance  toward  the  palmar  side.  This  separates  the 
nail  and  its  supporting  soft  tissue  from  the  tip  of  the  finger  and  the  tip  of  the 
bony  phalanx,  practically  turning  doAvn  a  palmar  flap  consisting  of  the  tip 
of  the  finger.  Por  drainage  a  thin  piece  of  rubber  tissue  is  placed  across  the 
bottom  of  the  incision  to  prevent  pocketing  and  to  facilitate  the  discharge 
of  pus  (Fig.  362).  The  resulting  scar  interferes  but  little  with  the  function 
of  the  tip  of  the  finger. 


THE    UPPER    EXTREMITIES  357 

Inllaminatioii  ai-ouiul  llie  nail,  or  jiaroiiycliia,  l^egins  around  the  site  of 
the  nail.  Tlie  inllaiinnatory  products  may  be  liberated  l)y  an  incision  that 
goes  downward  on  each  side  of  the  root  of  the  nail,  turning  back  the 
soft  tissue  as  a  liap  to  expose  the  infection.  It  is  important  to  remember 
that  the  bed  of  the  nail  near  its  root  should  be  disturbed  as  little  as  possible, 
and  any  incision  should  be  so  placed  as  to  avoid  this. 

In  deep  infections  of  the  hand  and  fingers,  if  recovery  is  not  prompt  after 
the  proper  application  of  hot  water  dressings,  an  incision  should  be  made. 
This,  however,  should  not  be  done  until  it  is  evident  that  either  the  condition 
is  not  improving  under  the  wet  dressing,  or  that  there  is  localization  of  the 
inflammatory  process. 

In  deep  infection  of  the  hand  incisions  can  only  be  satisfactorily  made 
under  a  general  anesthetic.  The  anatomy  of  the  hand,  particularly  of  the 
bursae,  should  be  borne  in  mind,  and  the  significance  of  the  fact  that  the 
tendon  sheaths  to  the  thumb  and  to  the  little  finger  communicate  with  the 
bursa  of  the  palm  of  the  hand  and  wrist  should  be  appreciated.  Consequently, 
infection  in  the  thumb  and  little  finger  is  potentially  more  dangerous  than 
infection  of  the  other  three  fingers.  When  the  index,  middle  or  ring  fingers 
are  infected  the  sheath  of  the  flexor  tendons  should  be  incised  where  the  in- 
fection appears  most  pronounced.  The  length  of  incision  will  depend  upon 
the  condition.  Sometimes  two  or  three  incisions  of  one-half  inch  in  length 
are  more  satisfactory  than  a  long  incision.  When  the  tendon  sheaths  of 
the  thumb  and  little  finger  are  infected  the  incision  should  open  the  bursa  in 
the  palm  of  the  hand  if  the  infection  has  shown  the  slightest  tendency  to 
travel  in  this  direction.  Sometimes,  however,  the  inflammatory  products 
will  wall  off  the  rest  of  the  bursa  and  it  should  not  always  be  taken  for 
granted  that  if  one  end  of  the  tendon  sheath  is  infected  therefore  the 
whole  of  the  bursa  is  involved.  Infection  of  the  middle  palmar  space  is 
taken  care  of  by  short  incisions,  preferably  in  the  creases  of  the  palm.  If  the 
infection  is  very  deep  and  appears  to  involve  the  back  of  the  hand  as  well 
as  the  palmar  aspect,  a  pair  of  forceps  is  carried  through  a  metacarpal  space 
and  pushed  to  the  back  of  the  hand.  A  small  rubber  tube  is  drawn  through, 
transflxes  the  hand,  and  affords  drainage  from  both  the  palmar  and  the 
dorsal  surfaces. 

Infection  of  the  thenar  space  may  be  reached  by  a  dorsal  incision  on 
the  radial  side  of  the  metacarpal  bone  of  the  index  flnger.  Sharp-pointed 
forceps  are  passed  from  this  point  into  the  infected  area  and  drainage  is  in- 
serted. Infection  above  the  annular  ligament  of  the  wrist  should  include 
not  only  longitudinal  incisions  in  this  region,  but  incisions  in  the  palm  of 
the  hand.  These  infections  are  best  opened  by  inserting  closed  forceps,  after 
incising  the  skin,  and  when  pus  is  reached  spreading  the  forceps  widely.  As 
shown  in  the  middle  of  the  last  century  by  Hilton,  this  is  much  better  than 
cutting  into  the  inflammatory  tissue. 

It  is  best  not  to  use  too  much  drainage  material  for  the  pressure  may  cause 
necrosis  and  lead  to  adhesions.  If  the  pus  is  abundant,  however,  and  rubber 
tissue  is  not  sufficient,  it  may  be  necessary  to  place  a  small,  soft  rubber  tube. 


358  OPERATIVE    SURGERY 

DEFORMITIES 

A  rather  common  lesion  is  wliat  is  known  as  Dupuytren's  contraction, 
which  is  a  contraction  of  the  palmar  fascia  and  of  those  extensions  of  the 
palmar  fascia  that  lead  to  the  fingers.  The  thumb  is  not  often  affected.  If 
the  skin  is  adherent  it  is  thrown  into  wrinkles.  The  condition  has  been 
remedied  by  different  types  of  operations,  depending  npon  the  severity  of 
the  disease.  Usually  only  one  or  two  fingers  are  involved.  Occasionally  all 
of  the  fingers  are  affected.  The  ring  finger  is  most  commonly  involved. 
Subcutaneous  incisions  with  a  tenotome  are  almost  never  curative,  as  the 
condition  rapidly  recurs.  The  most  satisfactory  operation  is  complete  ex- 
cision of  the  diseased  portion  of  the  palmar  fascia.  This  is  best  done  by 
an  incision  preferably  placed  so  that  it  will  not  result  in  a  longitudinal  scar 
in  the  palm  of  the  hand.  Often  a  triangular  flap  can  be  formed  by  a  trans- 
verse incision  across  the  palm  of  the  hand  which  follows  the  crease  of  the 
skin.  On  the  ulnar  side  another  incision  is  made  at  a  right  angle  to  the 
transverse  incision  and  triangular  flaps  of  skin  are  turned  back.  If  this 
does  not  afford  sufficient  room  another  longitudinal  incision  can  be  made  on 
the  radial  side  which  will  convert  the  incision  into  an  H  with  two  flaps,  one 
to  be  turned  downward  toward  the  flngers  and  the  other  upward  toward 
the  wrist.  It  may  be  necessary  to  split  the  distal  flap  in  order  to  excise 
the  contracted  portion  of  the  palmar  fascia  which  is  prolonged  on  to  the 
finger.  The  dissection  is  carefully  made,  taking  care  not  to  wound  the 
tendons.  It  is  essential  to  close  the  wound  completely,  leaving  no  raw  surface. 
After  excising  the  contracted  band  the  skin  itself  may  retract  to  such  an 
extent  that  it  is  impossible  to  bring  it  together  without  too  much  tension. 
Here  flaps  can  be  taken  from  the  radial  side  of  the  hand  or  from  the  back 
of  the  hand  and  turned  into  the  skin  defect.  In  aggravated  cases  in  which 
a  large  defect  of  the  skin  is  left  in  the  palm  after  dissecting  aAvay  the  con- 
tracted tissue,  the  proper  skin  covering  is  best  obtained  by  procedures  that 
have  been  described  in  the  chapter  on  Plastic  Surgery,  such  as  raising  a  flap 
from  the  abdominal  Avail,  leaving  the  base  attached,  and  suturing  the  apex  of 
the  flap  into  the  wound.  The  pedicle  is  gradually  divided.  Such  a  procedure, 
of  course,  is  only  indicated  in  extreme  cases. 

The  extensor  tendon  of  the  finger  is  occasionally  torn  in  injuries,  a  condi- 
tion which  is  particularly  common  in  baseball  players.  This  renders  complete 
extension  of  the  terminal  phalanx  impossible  and  results  in  what  is  known 
as  ''hammer"  finger  or  ''drop"  finger.  If  the  finger  is  seen  soon  after  the  in- 
jury a  splint  should  be  applied,  placing  the  finger  in  an  overextended  posi- 
tion until  healing  has  occurred.  The  splint  is  left  on  for  a  period  of  two 
or  three  weeks.  If  the  condition  is  not  markedly  better  after  this  treat- 
ment operation  is  indicated.  A  transverse  incision  is  made  on  the  dorsal 
surface  along  the  crease  of  skin  on  the  distal  portion  of  the  affected  joint. 
The  ends  of  the  incision  curve  slightly  downward  toward  the  nail  so  that  a 
flap  of  skin  is  turned  down  which  exposes  the  distal  portion  of  the  joint.  A 
short  longitudinal  incision  is  made  beginning  about  the  center  of  this  trans- 


THE   UPPER   EXTREMITIES 


359 


verse  incision,  at  a  ri<>lit  anti;le  to  it,  and  going  upward  in  lli(3  median 
dorsal  portion  of  the  second  phalanx.  The  two  ends  of  the  extensor  tendon 
are  dissected  and  united  with  sutures  of  fine  tanned  catgut.  The  wound  is 
closed  with  silk  or  fine  silkworm-gut  and  a  finger  splint  is  used  to  keep  the 
finger  in  extension  for  three  weeks. 

"Trigger"  finger,  or  "snapping"  finger,  occurs  when  flexion  or  exten- 
sion has  reached  a  certain  point  and  the  finger  appears  locked.  By  an  extra 
exertion  the  obstruction  is  overcome,  a  snap  occurs,  and  the  flexion  or  ex- 
tension is  completed.  This  condition  is  caused  by  some  obstacle  to  the  ac- 
tion of  the  tendons  which  is  usually  an  enlargement  of  a  tendon,  or  a  nar- 


Fig'.   363. — L,ine  of  incision  for  operation  for  webbed  lingers,  palmar  surface. 

rowing  of  the  tendon  sheath.  This  lesion  is  found  in  the  flngers  and  is  al- 
most always  in  the  space  between  the  palmar  fold  at  the  base  of  the  fingers 
and  the  first  crease  of  the  skin  on  the  palm.  The  tendon  is  exposed  by  an  in- 
cision over  it  and  if  the  trouble  is  due  to  a  fusiform  swelling  of  the  tendon, 
or  to  thickening  of  the  sheath,  the  sheath  is  split,  according  to  Weir,  and 
left  open,  and  the  skin  over  it  is  closed.  If  the  obstruction  is  due  to  a 
crumpling  up  of  the  flexor  tendons  by  a  transverse  band  of  fascia  in  this 
region,  as  suggested  by  Abbe,  the  fascia  should  of  course,  be  divided  by  a 
longitudinal  incision  in  the  region  where  most  of  such  trouble  occurs,  that 
is,  between  the  palmar  creases  at  the  base  of  the  fingers  and  the  next  crease 
in  the  palm  of  the  hand. 


360 


OPERATIVE    SURGERY 


Web  fingers  may  be  treated  on  the  general  principles  of  plastic  opera- 
tions. Usnally  a  flap  can  be  obtained  from  the  dorsal  surface  of  one  finger 
with  its  base  on  the  adjoining  finger  and  a  palmar  flap  made  in  a  reversed 
direction.  If  the  flaps  are  not  sufficiently  long  to  cover  the  raw  surface  of  the 
finger  with  skin  they  will  at  least  prevent  reunion  at  the  site  of  the  former  lo- 
cation of  the  web  and  the  raw  surface  on  the  dorsal  or  on  the  palmar  aspect  of 
tlie  finger  can  be  covered  with  skin  grafts  or  permitted  to  heal  by  granula- 
tions (Figs.  363;  364  and  365). 


Fig.   364. — Line   of  incision   for   operation  for   webbed   fingers,    dorsal   surface. 


Transplantation  of  tendons  of  the  forearm  is  sometimes  indicated  be- 
cause of  trauma  or  paralysis.  The  principles  of  tendon  transplantation  in 
the  upper  extremity  are  the  same  as  in  the  lower  extremity,  where  this 
operation  is  more  common  because  of  the  deformity  which  follows  infantile 
paralysis. 

Occasionally  after  traumatic  paralysis  of  some  nerve,  as  the  musculo- 
spinal, or  following  severe  infection  or  trauma  where  the  tendon  may  have 
been  destroyed  it  becomes  necessary  to  transplant  a  tendon  to  a  different 
insertion  from  the  normal  anatomical  insertion  or  to  reconstruct  a  section  of 
the   tendon   that   may   have   been   destroyed.      Certain    general   principles    in 


THE    UPPER    EXTREMITIES 


361 


transplaiUatiou  of  tendons  liave  been  eini)lia.size(l  by  ]Meyer^  and  should  be 
followed.  These  embrace  the  adjustment  of  a  transplanted  tendon  in  such 
a  maimer  that  when  the  muscle  is  relaxed  and  the  origin  of  the  muscle  and 
the  insertion  of  the  tendon  are  as  near  together  as  possible,  the  tension  on 
the  tendon  is  zero.  Thus  it  becomes  necessary  to  fix  the  tendon  in  its  loca- 
tion so  that  wlien  the  limb  is  in  such  a  position  as  to  approximate  the  origin 
of  the  muscle  and  the  insertion  of  the  tendon  as  closely  as  possible  there 
will  be  no  tension  on  the  transplanted  tendon.  Another  principle  is  that 
wherever  possible  the  sheath  of  the  paralyzed  tendon  should  be  used  as  a 
pathway  for  the  transplanted  tendon  or  the  tendon  should  be  invested  with 
loose  gliding-  tissue.     Wherever  possible  it  should  run  in  the  intermuscular 


Fig.  365. — The  flaps  as  outlined  in  the  two  preceding  drawings  have  been  dissected   and   are   being  sutured. 

plane  of  fascia.  If  the  tendon  perforates  this  fascia  it  is  sure  to  acquire  ad- 
hesions. When  such  tissue  is  impossible,  as  about  the  wrist  joint  for  in- 
stance, a  fatty  bed  is  provided.  If  the  neighboring  subcutaneous  tissue 
does  not  afford  sufficient  fat,  a  flap  with  subcuticular  fat  can  be  raised  from 
the  abdomen,  as  described  in  the  chapter  on  Plastic  Surgery,  and  the  ten- 
don or  tendons  to  be  transplanted  are  carried  through  a  tunnel  of  the  fat  by 
severing  the  tendon  and  then  suturing  it  together.  After  about  tw^o  wrecks 
the  base  of  the  pedicle  of  the  flap  is  gradually  severed,  the  tendon  together 
with  the  skin  and  subcuticular  fat  is  adjusted  on  the  forearm,  and  the  flap  is  su- 
tured into  its  new  location.  The  insertion  of  the  tendon  must  be  buried  beneath 
the  periosteum.  Function  should  be  begun  as  early  as  possible  in  order 
to  avoid  adhesions  in  the  transplanted  tendons. 

■     In  injuries  or  infections  about  the  wrist  or  hand  the  tendons  are  often 
destroved  and  it  becomes  necessary  to   reconstruct   them.     Dean   Lewis,-   of 


lAm.   lour.   Surg.,   1918,  xxxii.   No.   1. 
=Surg.,  Gynec.  &  Obst.,  February,   1917. 


362  OPERATIVE    SURGERY 

Chicago,  lias  done  excellent  work  in  reconstruction  of  tendons  of  the  hand. 
The  tendon  of  the  palmaris  longns  is  often  used  to  bridge  defects  though  it 
frequently  does  not  afford  sufficient  material  and  the  transplanted  tendon 
may  undergo  degeneration  and  become  adherent.  AVith  early  institution  of 
function,  however,  satisfactory  results  are  likely  to  be  obtained.  Passive 
or  active  motion  should  begin  three  or  four  days  after  the  transplantation 
of  tendons. 

According  to  Lewis  the  transplanted  tendon  at  the  end  of  three  weeks 
is  two  or  three  times  as  large  as  normal.  It  becomes  fusiform,  being  largest 
in  the  middle  and  diminishing  toward  both  ends.  The  enlargement  is  great- 
est in  the  third  Aveek  and  is  due  to  proliferative  changes  in  the  peritendineum 
as  well  as  to  swelling  in  the  transplant  from  insufficient  circulation.  While 
there  is  some  degeneration  in  all  transplanted  tendons  the  transplant  as  a 
Avhole  is  viable  and  does  not  act  as  a  bridge  to  convey  tenoblasts  from  one 
end  of  the  resected  tendon  but  ncAV  tissue  is  formed  from  the  transplant  it- 
self. If,  however,  the  tendon  is  transplanted  experimentally  Avhere  it  can- 
not function  the  proliferative  changes  do  not  occur,  but  the  tendon  atrophies 
without  any  attempt  at  proliferation.  Function  greatly  stimulates  the  pro- 
liferative changes. 


Fig.   366. — Method  of  applying  the   tendon   suture  of  Frisch. 

A  strip  of  fascia  lata  may  serve  as  a  tendon  and,  in  the  opinion  of  Lewis, 
is  preferable  to  tendon  for  repair  of  defects  in  the  tendons  of  the  hand.  Where 
the  injury  is  extensive  and  the  scar  tissue  dense  it  is  best  first  to  transplant 
a  flap  of  skin  from  the  abdomen  containing  much  subcutaneous  fat.  This 
should  be  abundant  enough  to  make  a  bulging  or  "humping"  in  the  region 
in  which  it  is  transplanted,  for  if  enough  fat  is  not  provided  it  is  difficult 
for  the  tendon  to  function  on  account  of  adhesions.  Some  of  the  excessive 
fat  will  be  absorbed  and  if  objectionable,  some  may  be  removed  later. 
After  the  skin  and  fat  flap  from  the  abdomen  has  become  acclimated  and  its 
nutrition  established  in  its  new  location,  reconstruction  of  the  tendons  is 
begun,  [f  this  is  done  with  strips  of  fascia  lata,  as  Lewis  prefer.s,  the  .sub- 
cutaneous fat  is  tunnelled  with  an  artery  forceps  so  that  the  transplant  of 
fascia  lata  will  run  entirely  through  a  fatty  tunnel.  AYhen  the  muscles  are 
thrown  into  action  the  sutures  should  hold  the  ends  of  the  transplant  well 
approximated  'to  the  tendon  that  is  its  host.  Tendons  cannot  be  sutured 
by  simple  interrupted  sutures  as  they  Avill  cut  out.  The  tendon  suture  of 
Frisch^  is  very  satisfactory  (Fig.  366).  The  play  of  the  flexor  tendons  of  the 
forearm  is  greater  than  the  play  of  the  extensors,  so  interference  by  adhesions  is 
more  marked  with  the  flexor  tendons.     In  the  flexor  tendon  a  tube  of  fascia 


'Surg.,   Gynec.   &  Obst.,  February,   1917,  p.   132. 


THE   UPPER   EXTREMITIES 


363 


lata  is  used  inslead  of  a  strip  \vhicli  will  suffic^e  Tor  an  extensor  tendon. 
When  the  skin  on  the  llexor  side  of  the  fingers  has  l)een  destroyed  and  is 
replaeed  by  scar  tissue,  new  skin  is  first  transplanted  along  Avith  subcutane- 
ous fat  after  ]-emoving  the  scar.  When  this  has  become  well  established 
the  fascial  tube  used  to  reconstruct  the  defect  in  the  flexor  tendon  is  carried 


Fig.  367.— Transplantation  of  tendon  of  the  flexor  carpi  radialis  for  paralysis  of  the  extensor  muscles  of  the 
forearm  according  to  J.  B.  Murphy.     The  tendon  is  divided  and  a  tunnel  is  formed  under  the  SKin. 


through  small  incisions  and  a  tunnel  is  made  in  the  fat  of  the  transplanted  skin. 
The  fascial  tube  should  surround  the  end  of  the  tendon  on  the  proximal  side 
and  can  be  firmly  attached  by  the  Frisch  suture  to  the  tendon.  The 
fascial  tube  is  made  with  the  fat  side  internal.  The  end  of  the  reconstructed 
tendon,  after  being  carried  through  the  subcutaneous  fat,  is  sutured  to  the 
pei'iosteum  in  the  region  of  the  normal  insertion  of  the  tendon.     In  order 


364 


OPERATIVE   SURGERY 


to  simulate  the  bands  that  prevent  the  tendon  from  strutting  with  tiexion  a 
ring  may  be  worn  over  the  finger. 

McArthur  suggests  implanting  the  fascial  strip  in  the  fat  before  it  is 
removed.  The  strip  of  fascia  to  be  transplanted  is  dissected  up  but  left 
attached  at  both  ends,  subcutaneous  fat  is  placed  about  it  and  the  wound 
closed.    Six  weeks  later  the  wound  is  reopened  and  the  strip  of  fascia  along 


Fig-.   368.— A  skin  incision  is  made   four  inches   higher  and  the  tendon   is   drawn   through. 


with  its  surrounding  attached  fat  is  transferred  to  the  forearm  and  hand  and 
sutured  in  position.     This  seems  to  be  an  excellent  procedure. 

John  B.  Murphy  transplanted  tendons  from  the  flexor  surface  of  the 
forearm  to  the  extensor  tendons  in  order  to  overcome  paralysis  of  the  muscu- 
lospiral  nerve.  This  was  accomplished  in  the  f oUoAving  manner :  The  tendon 
of  the  flexor  carpi  radialis  is  divided  .just  below  the  annular  ligament  through 


TIIK    UPPER    EXTRF.MITIKS 


365 


a  short  loiiiiiliidiiKil  im-isioii.  lilunt  dissection  willi  ]()iii>'  scissors  is  carried 
up  about  four  iiu-lies  beuciilli  the  skin  as  far  as  tlie  muscle  of  the  tendon. 
This  is  done  by  inserting'  the  scissors  closed  and  spreading'  the  blades,  then 
witlulrawing  and  inserting-  the  closed  scissors  again  (Fig.  367).  Another  in- 
cision is  made  at  the  upper  point  of  this  blunt  dissection  about  four  inches 
above   the  annular  ligament   and   the   tendon   of   the   flexor   carpi   radialis   is 


Fig.    369.— A   third  incision   is   made   on   the   back   of  the   wrist   and   the   tendon   of   the   flexor   carpi   radialis 

is   pulled   through. 

drawn  through  this  incision  (Fig.  368).  This  gives  the  tendon  the  proper 
angle  for  its  maximum  amount,  of  contraction.  A  short  vertical  incision  is 
then  made  on  the  back  of  the  Avrist  over  the  extensor  tendons  of  the  fin- 
gers and  closed  forceps  are  pushed  through  from  this  incision  to  the  upper 
incision  on  the  forearm,  grasping  the  end  of  the  tendon  of  the  flexor  carpi 
radialis  and  pulling  it  through  the  tunnel  made  by  the  forceps  to  the  incision 


366 


OPERATIVE    SURGERY 


on  the  back  of  the  wrist.  This  tiuniel  is  made  in  the  suljcuticuhir  i'at  (Fig. 
369).  The  tendon  passes  through  the  split  tendons  of  the  extensor  longus 
and  extensor  brevis  poUieis,  the  two  extensor  tendons  of  the  index  finger, 
and  the  extensor  tendon  of  each  of  the  other  fingers.  This  insertion  is  made 
in  such  a  way  that  the  tendons  of  the  thumb  and  index  finger  receive  the 
greatest  amount  of  pull,  though  when  full  extension  is  made  all  five  fingers 
are  extended  (Fig.  370).  The  thumb  and  index  finger,  however,  can  be 
slightly  extended  without   extending  the  other  three  fingers. 

Obstruction  of  the  lymphatics  of  the  arm  produces  marked  swelling. 
This  occurs  not  infrequently  after  cancer  of  the  breast  and  if  it  appears 
several  weeks  or  months  after  a  radical  operation  for  cancer  it  is  probably 
due  to  the  blocking  of  the  lymphatic  channels  with  cancer  cells.     Operations 


Fig'.   370. — The  tendon  is   inserted  into  the   extensor  tendons   of  all   five   fingers   in   such  a  manner  that   the 
pull  will   be  first  exerted   on  the  thumb  and   index   finger. 

for  edema  of  the  arm  and  forearm  following  cancer  give  but  temporary 
relief,  but  occasionally  even  this  is  justifiable.  In  the  rare  instances  in  which 
the  blockage  is  not  due  to  malignant  disease,  operation  may  be  indicated. 

According  to  the  method  of  Handlej^  an  incision  about  one  inch  long 
is  made  through  the  skin  in  the  front  of  the  forearm  immediately  above  the 
wrist,  A  long  probe  with  an  eye  at  the  proximal  end  is  introduced  through 
this  incision  and  -is  pushed  upward  and  outward  beneath  the  skin  to  a  point 
near  the  elbow.  It  is  cut  down  upon  and  exposed.  The  probe  is  threaded 
with  a  long  line  of  doubled  stout  silk  and  this  is  drawn  through  from  the 
lower  incision  to  the  upper  incision.  The  thread  is  clamped  at  the  level 
of  the  lower  incision  so  that  only  one-half  of  it  can  be  drawn  through.  The 
probe  is  reintroduced  in  the  incision  at  the   elbow  and  pushed  under  the 


THE   UPPER   EXTREMITIES 


367 


skill  1<)  ;i  point  on  llic  iiriii  over  1lu>  iiisciiioii  (if  1lu'  deltoid  ;iiid  tlic  silk 
is  cari'icd  witli  it  and  is  unthreaded.  The  i)rol)e  is  again  iiitrodueed  at  the 
original  ineislon  above  the  wrist,  threaded  with  tlie  other  end  of  tlie  silk 
and  is  inished  inward  and  u])\vard  and  made  to  appear  through  a  short  in- 
eisioii  ill  the  skin  on  the  inner  side  of  the  elbow.  The  probe  carries  the 
other  end  of  the  thread  (Fig.  371).  From  this  point  it  eari-ies  the  thread 
throngh  to  the  upper  incision  over  the  insertion  of  the  deltoid  and  from 
there  liotii  probes  are  introduced  under  the  skin  and  carry  both  threads 
to  the  back  of  the  arm  to  an  incision  made  in  the  posterior  border  of  the 
deltoid.       By  a  similar  procedure  silk  is  buried  under  the  skin  on  the  back 


p[g     37 1_ — Placing    of    silk    threads    on    anterior    surface    of    arm    and    forearm    to    relieve    swelling    of    the 

upper  extremity.      (Handley.) 
Fig.    372. — Placing  of  silk   threads   on   the   posterior   surface   of  the   arm    and   forearm. 

of  the  forearm  and  the  silk  made  to  appear  throngh  the  incision  in  the  skin 
at  the  posterior  border  of  the  deltoid.  The  ends  of  the  four  threads 
are  now  cut  so  they  will  be  shorter  than  the  probe  and  one  of  the 
four  ends  that  emerge  through  the  npper  posterior  incision  is  threaded  into 
a  probe  and  the  probe  is  thrust  full  length,  eye  first,  through  the  npper  poste- 
rior incision  nnder  the  skin  of  the  back  over  the  region  of  the  scapnla,  and  so 
the  probe  is  unthreaded  and  leaves  the  silk  in  the  tunnel  made  by  the  probe. 
The  probe  is  then  withdrawn  and  the  procedure  is  repeated  till  all  four  of 
the  silk  threads  have  been  placed  in  different  directions.  In  this  way  the 
threads  are  carried  in  a  radiating  manner  under  the  skin  of  the  back  (Fig. 
372).     The  incisions  are  closed  Avith  sutures.     This  operation  of  Handley  is 


368 


OPERATIVE    SURGERY 


devised  to  create  new  lymphatic  cliaiinels  al()ii<>'  llie  llircads  and  so  1o  iiici'ease 
the  flow  of  lymph  along  the  newly  created  lym])li  cliaimcls  as  1o  rclicxc  1lic 
edema. 

The  operation  of  Kondoleon  depends  upon  a  different  principle.  While  the 
operation  of  Handley  seems  to  create  new  lymphatic  channels  that  of  Kon- 
doleon promotes  anastomosis  between  the  superficial  and  deep  lymphatics.  If 
both  sets  are  blocked  the  operation  of  Handley  is  indicated  but  if  the  swelling 


Fig.    373. — Lines   of   incision   for   operation   of   Kondoleon    along   the    outer   border   of   the    upper   extremity. 

is   due   to    obstruction   in   the    superficial   lymphatics,   when   the    deep    set   is 
free  from  obstruction,  the  operation  of  Kondoleon  is  best. 

Sistrunk,*  of  the  Mayo  Clinic,  has  obtained  very  satisfactory  results 
from  the  Kondoleon  operation.  A  long  narrow  elliptical  incision  is  made 
on  the  outer  aspect  of  the  limb  extending  from  the  wrist  to  a  few  inches 
below  the  shoulder  joint  (Figs.  373  and  374).  The  skin  incision  is  so  made 
that  the  wound  can  be  readily  closed.  The  skin  is  retracted  and  under  each 
edge  of  the  retracted  skin  a  long  cut  is  made  through  the   edematous  fat 


Fig    374.— Lines  of  incision   for  operation  of  Kondoleon  along  inn:r  border  of   the   upper  extremity. 

down  to  and  through  the  deep  fascia.  A  piece  of  tissue  including  the  skin, 
much  of  the  undermined  fat,  and  a  strip  of  fascia,  is  removed.  The  vessels 
are  carefully  clamped.  The  edges  of  the  fascia  may  be  turned  under  and 
sutured  to  the  -muscle,  though  if  a  sufficient  strip  of  fascia  has  been  removed 
this  is  not  necessary.  The  skin  is  approximated  in  the  usual  manner  without 
drainage.  If  this  is  not  satisfactory  a  similar  incision  can  be  made  on  the 
inner  side  of  the  arm  a  few  weeks  later. 


^Jour.  Am.  Med.  Assn.,  1918,  Ixxi,  p.  800. 


THE    UPPER    EXTREMITIES  oiii) 


SUBACROMIAL  BURSITIS 


CodiiKui,   of  Boston,   has  described  an   inllammation  of  the   subacromial 
bursa,  which  is  often  responsible  for  trouble  with  the  shoulder  joint.     This 
affection  is  frequently  accompanied  by  deposits  of  lime  salts  in  the  tendon 
of  the  supraspinous  muscle  and  Brickner  thinks  that  tears  or  bruises  of  this 
tendon  are  often  followed  by  the  deposit  of  lime  salts  on  its  surface.     When 
these  deposits  are  present  with  subacromial  bursitis  it  is  necessary  to  remove 
them.    Codman  advises  operation  by  making  an  incision  from  a  point  midway 
between  the  coracoid  and  the  acromion  processes  downward  about  two  and 
one-half  inches,  splitting  the  fibers  of  the  deltoid  muscle.     The  bursa  should 
be  cut  down  upon  carefully  as  in  entering  the  peritoneum  and  its  surface  is 
recognized  and  incised.     As  much  of  the  adherent  or  thickened  bursa  is  re- 
moved as  possible  and  the  wound  is  closed  in  layers.    Motion  should  be  begun 
in  about  ten  days.     Brickner  opens  the  bursa  from  an  incision  which  goes 
downward  from  the  outer  border  of  the  acromion  over  the  greater  tuberosity 
of  the  humerus  toward  the  external  condyle.     The  fibers  of  the  deltoid  muscle 
are  split  and  retracted.    The  bursa  is  carefully  opened  and  adherent  bands  are 
divided.    By  rotating  the  arm  the  whole  subacromial  bursa  is  explored.     The 
floor  of  the  bursa  is  then  incised  in  the  same  line  as  the  skin  incision  over  the 
greater  tuberosity  of  the   humerus   and   the   insertion   of   the   supraspinatus 
tendon  is  exposed.     The  bursa  is  dissected  from  the  tendon  and  any  deposits 
of  lime  salts  are  removed.     If  the  tendon  shows  evidence  of  an  injury  this  re- 
gion is  trimmed  away  and  the  tendon  is  sutured.    If  the  roentgenogram  has  shown 
deposits  of  lime  salts  in  the  tendon  these  should  be  removed  by  splitting  the  ten- 
don dow^i  to  the  deposits,  and  after  removing  the  lime  salts  the  tendon  is  sutured 
with  catgut.  The  wound  in  the  floor  of  the  bursa  is  closed  with  fine  catgut  stitches 
and  the  roof  of  the  bursa  is  similarly  closed.     The  deltoid  and  the  skin  are 
sutured  separately  and  the  arm  is  placed  in  the  position  of  abduction  until 
healing  takes  place. 

Codman  operates  to  restore  the  supraspinatus  tendon  if  it  has  been  in- 
jured by  being  pulled  from  its  insertion  into  the  head  of  the  humerus,  by 
making  an  incision  as  in  his  operation  for  subacromial  bursitis  and  then 
continuing  the  upper  end  of  the  incision  over  the  root  of  the  acromion  process 
directly  back  over  the  shoulder.  The  acromio-clavicular  joint  is  divided. 
The  base  of  the  acromion  is  severed  with  a  wire  saw,  care  being  taken  to 
avoid  injury  to  the  suprascapular  nerve.  A  small  portion  of  the  trapezius 
muscle  is  divided  and  the  acromion  process  along  the  deltoid  and  the  outer 
half  of  the  w^ound  is  retracted  outward.  If  the  supraspinatus  muscle  has 
been  torn  the  articular  portion  of  the  joint  is  visible,  but  if  the  operation 
is  merely  exploratory,  this  muscle  must  be  divided  before  the  joint  can  be 
seen.  The  tendons  are  sutured  with  tanned  catgut  and  the  acromion  process 
is  united  by  tanned  catgut  or  tendon  sutures  passed  through  drill  holes  on 
either  side  of  the  saw  line. 


CHAPTER  XIX 
OPERATIONS  OX  THE  LOWER  EXTRE:\riTY 

AMPUTATIONS 

The  same  general  principles  that  have  been  emphasized  in  amputations  of 
the  upper  extremity  also  apply  to  amputations  of  the  lower  extremity.  The 
problems  are  slightly  different,  however,  because  of  the  necessity  of  weight 
bearing  on  the  stump  of  the  leg,  for  which  there  is  no  occasion  after  ampu- 
tation of  the  arm.  The  ^Yorld  War  has  thrown  much  light  upon  the  problem 
of  amputation,  particularly  concerning  the   most   efficient   stump. 

Starr^  speaks  of  the  desirability  of  having  an  ideal  stump  in  leg  amputa- 
tions. He  defines  such  a  stump  as  one  that  is  best  suited  for  an  artificial  ap- 
pliance for  that  portion  of  the  leg.  The  ideal  stump  should  have  a  linear 
scar,  be  free  from  puckering  or  infolding  of  the  skin,  and  with  sufficient  flap 
but  no  redundancy.  There  should  be  a  pad  of  fat  and  subcutaneous  tissue 
over  the  head  of  the  bone,  but  it  should  not  be  adherent.  The  joint  next 
above  the  amputation  must  have  a  full  range  of  motion.  Such  a  stump  is  not 
often  obtained,  but  it  should  be  kept  in  mind  and  an  effort  made  to  secure  it 
whenever  amputation  is  necessary. 

The  guillotine  operation  is  even  more  unsatisfactory  in  the  lower  extremity 
than  in  the  upper  extremity  and  should  but  seldom  if  ever  be  done.  It  probably 
provides  but  little  if  any  more  against  infection  than  the  other  types  of  amputa- 
tions and  it  makes  a  secondary  operation,  as  a  rule,  imperative.  The  better  meth- 
ods of  dealing  with  infection  have  caused  the  guillotine  operation  to  be  discarded. 

Stumps  may  harbor  infection  either  in  the  soft  tissues  or  in  the  bone,  and 
in  military  surgery  there  is  very  apt  to  be  a  foreign  body  which  will  cause 
an  ulcer  or  a  sinus.  A  stump  which  shows  a  persistent  ulcer  or  sinus  should 
be  operated  upon  under  a  tourniquet,  the  sinus  or  ulcer  excised  well  into 
healthy  tissue,  and  diseased  bone  or  foreign  body  removed  if  present.  This 
is  much  better  than  blindly  scraping  with  a  euret  in  a  bloody  field. 

Spurs  of  bone  are  sometimes  the  cause  of  pain  and  may  be  due  to  the 
snapping  off  of  the  last  portion  of  the  bone  before  sawing  has  been  completed, 
or  to  the  lack  of  proper  removal  of  the  periosteum  and  endosteum. 

Painful  neuromas  are  best  avoided  by  following  the  suggestion  of  Huber 
and  Lewis,  which  has  already  been  mentioned,  and  injecting  tlie  nerve  trunk  with 
alcohol  just  above  the  point  of  section.  The  nerve  should  be  well  pulled  down  so 
that  after  section  it  will  retract  into  the  soft  tissues.  Starr  finds  that  ampu- 
tation of  the  toes  with  a  plantar  flap  causes  almost  no  disability.  One  toe 
should  never  be  left,  for  it  becomes  deformed  and  is  of  no  use.     The  tarso- 


ijour.  Am.  Med.  Assn.,  Nov.  22     1919,  pp.  1585-1590. 

370 


THE    LOWER   EXTREMITY  371 

metatarsal  ainputation  is  satisfactory,  aceorclijig  to  Starr,  if  the  peroneus 
muscles  are  lel't  intact  on  the  outside  aud  the  tibial  on  the  inside.  The 
midtarsal  amputation,  hoAvever,  results  in  an  unbalanced  foot  with  elevation 
of  the  heel  and  gives  a  stump  that  cannot  be  properly  fitted  either  with  an 
artificial  foot  or  boot.  This  method  of  amputation,  which  is  known  as  the 
classical  Chopart,  should  never  be  done.  In  its  stead  the  Syme  operation 
gives  excellent  results  when  properly  performed. 

Amputation  of  the  leg  should  not  be  done  within  four  inches  of  the  ankle 
joint,  because  a  stump  too  near  the  ankle  will  make  it  impossible  satisfactorily 
to  fit  an  artificial  leg.  Above  this  point,  however,  the  longer  the  stump  the  more 
helpful  will  be  the  application  of  an  artificial  appliance,  because  there  is  greater 
leverage  and,  consequently,  better  walking  and  less  limping. 

According  to  Starr  the  term  ''site  of  election,"  as  applied  to  leg  ampu- 
tations should  be  dropped,  for  it  is  a  source  of  confusion.  Below  the  knee 
the  stump  may  be  so  short  as  to  be  useless.  In  the  thigh  the  lower  the  stump 
the  better  the  leverage.  The  Gritti-Stokes  amputation  is  one  of  the  best  thigh  am- 
putations when  an  artificial  limb  is  to  be  used.  In  elderly  people  with  gan- 
grene of  the  foot  or  leg  the  Stephen  Smith  operation  through  the  knee  is 
exceedingly  good  and  easily  performed.  The  chief  fault  of  the  Gritti-Stokes 
operation  is  that  the  approximation  of  the  patella  to  the  end  of  the  femur 
is  often  unsatisfactory  and  unequal.  A  stump  shorter  than  five  inches  from 
the  perineum  can  rarely  be  fitted  with  an  artificial  leg  without  a  pelvic 
band.  After  amputation  at  the  trochanter  minor  or  above  this  point,  includ- 
ing amputation  at  the  hip  joint,  it  is  necessary  to  have  a  ''pelvic  cradle"  or 
"tilting  table",  as  it  is  called  by  the  English  manufacturers,  which  has  an 
automatic  lock  both  at  the  hip  and  the  knee. 

Aside  from  the  Syme  amputation  at  the  lower  end  of  the  tibia  and  the 
Gritti  at  the  lower  end  of  the  thigh,  a  complete  end  bearing  stump  is  rarely 
possible,  according  to  Starr,  though  by  a  hammock  suspended  in  a  bucket 
the  stumps  may  take  much  of  the  weight. 

Amputation  through  the  knee  joint  is  difficult  to  fit  with  an  artificial 
appliance,  as  the  joint  must  necessarily  be  much  lower  than  the  normal 
knee  joint ;  but  if  good  covering  is  provided  for  the  condyles,  preferably  with 
an  anterior  flap,  it  will  make  a  fairly  good  end  bearing  stump.  Because  of 
the  liability  of  infection  in  military  surgery  some  operators  prefer  this  type 
of  amputation  to  the  Gritti-Stokes,  thinking  that  in  the  latter  operation  it  is 
difficult  to  obtain  satisfactory  results  in  the  presence  of  infection. 

Amputation  of  the  toes  may  be  done  in  the  same  general  way  as  amputa- 
tion of  the  fingers  (Fig.  375).  The  insertion  of  the  tendons  and  their  general 
arrangement  in  the  foot  are  similar  to  the  insertion  in  the  hand.  As  much  tissue 
as  possible  should  be  saved  if  it  can  be  sufficiently  nourished.  The  great  toe 
is  exceedingly  important  and  is  far  more  valuable  than  any  other  toe.  The 
distal  end  of  the  first  metatarsal  bone  should  also  be  preserved  wherever 
possible,  as  it  constitutes  the  anterior  pedestal  of  the  plantar  arch.     It  is 


372 


OPERATIVE    SURGERY 


essential  that  in  all  ^imputations  of"  tlic  toe  the  sear  should  fall  on  the  dorsum 
of  the  foot  and  not  on  the  plantar  surface.  As  the  toes  are  short,  disarticu- 
lation is  usually  done  and  there  is  not  often  occasion  to  amputate  through 
the  bone.  The  length  of  the  flap  is  one  and  one-half  times  the  diameter 
of  the  toe  and  it  should  be  a  plantar  flap.  If  a  full  plantar  flap  cannot  be  ob- 
tained the  racket  or  oval  method  may  be  used.  Amputation  or  disarticula- 
tion of  the  great  toe  at  the  metatarsophalangeal  joint  is  best  done  by  a  type 
of  racket  incision  that  begins  over  the  middle  of  the  joint  on  the  dorsum  of 
the  foot  and  is  carried  along  the  junction  of  the  upper  and  inner  sides  of  the 
great  toe  to  the  distal  end  of  the  first  phalanx.  From  this  point  the  incision 
curves  around  the  inner  surface  of  the  toe,  then  the  under  surface,  and 
finally  along  the  outer  surface  of  the  toe  to  the  Aveb  and  to  the  point  of  be- 
ginning of  the  incision.  It  must  be  remembered  that  in  speaking  of  inner  or 
outer  portion  of  the  tee  in  an  anatomical  sense  the  outer  portion  is  that  nearest 


Fig.  375. — Lines  of  incision  for  amputation  of  the  toe:  A.  disarticulation  of  the  middle  toe  with 
its  metatarsal  bone;  B,  disarticulation  of  the  two  outer  toes  with  their  metatarsal  bones;  C,  amputation  of 
the  first  toe;  D,  E,  F,  and  G,  the  lines  of  different  types  of  incision  for  amputation  of  the   toes. 

the  little  toe.  The  flexor  and  extensor  tendons  are  divided  about  the  middle 
of  the  first  phalanx  so  that  these  tendons  can  be  sewed  together  across  the 
end  of  the  stump.  The  joint  is  opened  on  the  dorsum  and  the  capsular  liga- 
ment is  divided  close  to  the  phalanx  in  order  to  leave  as  much  as  possible 
to  cover  the  end  of  the  bone.  The  flexor  tendons  may  be  sutured  to  the  ex- 
tensors. If  this  cannot  be  done  the  sheath  of  the  flexors  should  be  closed 
with  sutures.  If  this  type  of  operation  is  not  desirable  on  account  of  the  in- 
jured tissue,  a  long  plantar  flap  serves  an  excellent  purpose.  Any  one  of  the  other 
toes  can  be  disarticulated  or  amputated  at  the  metatarsophalangeal  joint  and 
if  a  long  plantar  flap  cannot  be  secured  the  racket  incision  with  the  straight 
incision  on  the  dorsum  of  the  toe  and  extending  down  over  the  metatarsal 
bone  gives  good  results.  If  possible  the  flexor  and  extensor  tendons  should 
be  cut  long  so  they  can  be  sewed  over  the  stump. 


THE    LOWER    EXTREMITY 


373 


If  it  is  neeessai-y  to  amputate  four  toes  tlie  remaining  one  sliould  also  be 
amputated. 

In  disease  of  a  metatarsal  bone  the  metatarsal  bone  and  the  corresponding 
toe  can  be  removed  by  a  long  dorsal  incision  over  the  metatarsal  bone  which 
ends  in  an  oval  iiu'isiou  surrounding  tlie  toe  and  forming  a  sufficiently  long 
plantar  Ihi])  to  prevent  the  sear  from  lying  on  the  bottom  of  the  foot.  The 
incision  begins  on  the  dorsum  of  the  bone  to  be  removed  about  opposite 
the  metatarsotarsal  joint.  It  must  be  remembered  that  the  metatarsal 
bone  of  the  second  toe  fits  back  slightly  farther  in  the  tarsus  than  do  the 


Fig.    376. — Lines    of   incision   for    amputation    at    the    tarsometatarsal    joint    (Lisfranc's    aminitation) . 

other  metatarsal  bones.  The  extensor  tendon  is  divided  through  the  upper 
portion  of  the  incision.  In  the  great  toe  or  the  little  toe,  however,  the  ten- 
dons are  divided  if  possible  at  a  point  sufficiently  below  the  site  of  am- 
putation to  permit  the  flexor  and  extensor  tendons  to  be  sewed  together, 
or  at  least  to  be  attached  to  the  periosteum.  In  the  other  toes  the  tendons 
are  of  no  great  importance  when  the  metatarsal  bone  is  to  be  removed. 
If  the  bone  is  to  be  divided  and  not  disarticulated  a  wire  saw  should  be 
used,  being  careful  to  protect  the  soft  tissues.  Amputation  or  disartic- 
ulation of  two  or  more  toes  with  their  metatarsal  bones  can  be  done  with 
a  racket  incision  that  is  merely  an  extension  of  the  same  type  of  incision 
used  for  amputation  or  disarticulation  of  a  single  toe.  It  must  always 
be  borne  in  mind  to  secure  as  much  of  the  plantar  flap  as  possible.  It 
may  be  necessary  to  afford  exposure   of  the  base   of  the  metatarsal   bones 


374  OPERATIVE    SURGERY 

by  an  additional  T-shaped  or  L-shaped  extension  at  the  end  of  the  long 
racket  incision.  If  the  outer  metatarsal  or  the  inner  metatarsal  bones  are 
to  be  removed  along  with  the  toes  the  incision  should  be  so  shaped  as  to  have 
a  long  plantar  and  a  short  dorsal  flap. 

Amputation  at  the  tarsometatarsal  joint,  or  Lisfranc's  amputation,  gives 
very  satisfactory  results  (Fig.  376).  The  incision  begins  with  the  foot  in 
plantar  flexion  at  a  point  just  posterior  to  the  base  of  the  metatarsal  bone  of 
the  little  toe  and  is  carried  in  a  slightly  curved  direction  forward  along  the 
outer  side  of  the  foot  about  one  inch.  Then  the  incision  curves  across  the 
dorsum  of  the  foot  one-half  an  inch  below  the  line  of  the  tarsometatarsal 
joint  and  is  carried  backward  to  the  inner  side  of  the  foot  a  short  distance 
behind  the  base  of  the  metatarsal  bone  of  the  great  toe.  Care  should  be 
taken  to  protect  the  insertions  of  the  peroneus  muscles  and  of  the  tibialis 
anticus  on  the  outer  and  inner  sides  of  the  foot.  The  extensor  tendons  are  di- 
vided and  the  incision  is  carried  down  to  the  joint.  As  this  is  done  the  foot  is 
bent  forward  so  as  to  expose  the  joint.  The  dorsal  flap  contains  as  much 
of  the  subcutaneous  tissue  as  possible  and  is  dissected  up  just  above  the 
tarsometatarsal  joint.  The  plantar  flap  begins  at  the  point  of  beginning  of  the 
dorsal  flap,  that  is  just  posterior  to  the  base  of  the  fifth  metatarsal  bone,  and 
is  carried  forward  and  slightly  iuAvard.  It  curves  across  the  sole  about  op- 
posite the  heads  of  the  metatarsal  bones  and  is  carried  to  the  point  of  ter- 
mination of  the  dorsal  flap  on  the  inner  side  of  the  foot.  The  plantar  flap 
should  be  somewhat  longer  on  the  inner  side  than  on  the  outer,  because 
there  is  more  bony  surface  to  cover  in  this  region.  The  incision  for  the 
flap  is  carried  down  to  the  bone,  taking  care  to  protect  the  plantar  arteries. 
The  flap  is  dissected  back  to  a  point  just  above  the  tarsometatarsal  joint 
and  includes  all  the  flexor  tendons  and  other  soft  parts  down  to  the  bone. 
The  joint  is  disarticulated  by  first  dividing  the  dorsal  ligaments  with  a 
strong,  narrow  bladed  knife,  beginning  at  a  point  between  the  first  meta- 
tarsal bone  and  the  internal  cuneiform.  The  knife  is  then  firmly  inserted  be- 
tween the  first  and  second  metatarsal  bones,  carried  backward  to  the  base 
of  the  second  metatarsal  bone,  and  a  similar  cut  is  made  between  the  second 
and  third  metatarsal  bones.  Then  the  joint  between  the  second  metatarsal 
and  the  middle  cuneiform  is  severed  by  a  transverse  incision.  The  rest  of 
the  metatarsal  bones  are  separated  from  the  tarsus  by  opening  the  joint  from 
above  downward.  If  there  is  any  difficult}^  about  disarticulating  the  second 
metatarsal  bone  on  account  of  its  deep  insertion  its  base  may  be  sawed  across. 
This  will  give  a  very  satisfactory  stump.  It  is  much  better  to  do  this  than 
to  adopt  the  suggestion  of  Hey  and  saw  off  a  part  of  the  internal  cunei- 
form bone,  as  this  may  affect  the  insertion  of  the  tibialis  anticus  to  such  an 
extent  as  to  jeopardize  the  usefulness  of  the  foot.  The  arteries  are  tied. 
They  include  the  dorsal  interosseous,  the  communicating  branches  of  the 
dorsalis  pedis,  the  four  digital  arteries  in  the  plantar  flap,  the  two  terminal 
communicating  branches  of  the  dorsalis  pedis,  the  internal  plantar  and  some 
times  the  external  plantar.     The  flexor  and  extensor  tendons  are  served  to- 


THE    LOWER   EXTREMITY 


375 


gether  over  the  bone  in  order  to  give  better  control  of  the  stump,  and  then 
the  plantar  and  dorsal  flaps  are  approximated.  If  there  is  too  great  a  ten- 
dency for  the  heel  to  be  pulled  up,  the  tendo  Achillis  should  be  cut. 

The  operation  of  Chopart,  or  disarticulation  of  the  foot  through  tlie 
midtarsus,  has  been  practically  discarded  as  the  insertion  of  the  anterior  ten- 
dons are  cut  away,  and  tliere  is  nothing  to  oppose  action  of  the  tendo  Achillis. 
This  operation  makes  an  unbalanced  foot  and  it  should  not  be  done.  The 
Pirogoff  amputation,  in  which  the  posterior  portion  of  the  os  caleis  is  fixed 
to  the  lower  end  of  the  tibia,  and  the  malleoli  have  been  sawed  off,  has  not 
given  satisfactory  results  and  is  difficult  of  execution.  The  modification  in 
whicli  the  os  caleis  is  sawed  transversely  instead  of  vertically,  as  in  the  Piro- 
goff operation,  seems  theoretically  better,  but  practically  the  results  are  no 
better.  The  Syme  operation  seems  to  be  the  most  useful  of  any  operation 
in  the  region  of  the  ankle  joint.    If  amputation  cannot  be  done  at  the  tarso- 


Fig.    377. — Eines  of  incision  for  amputation   of  Syme  at   the  ankle. 


metatarsal  joint,  the  Lisfranc  operation,  the  next  site  would  be  just  above  the 
ankle  according  to  the  method  of  Syme. 

In  Syme's  ami3utation  an  incision  is  made  to  the  bone  from  the  tip  of  the 
external  malleolus  down  across  the  sole  of  the  foot  to  a  point  about  one- 
half  inch  below  the  internal  malleolus.  The  center  of  the  incision  is  curved 
very  slightly  toward  the  heel.  The  upper  ends  of  this  incision  are  joined 
by  a  straight  incision  carried  across  the  front  of  the  ankle  joint.  (Pig. 
377.)  The  foot  is  bent  strongly  downward  and  the  ankle  joint  is  freely 
opened  from  the  front,  dividing  also  the  lateral  ligaments.  Great  care 
should  be  taken  in  dissecting  the  soft  parts  on  the  inner  side  of  the  ankle  to 
avoid  injury  to  the  posterior  tibial  artery  and  its  branches,  as  this  is  the 
most  important  supply  of  nutrition  to  the  flaps.  As  the  joint  is  further 
opened  the  tendo  Achillis  and  the  heel  flap  are  dissected  from  the  os  caleis 
from  above  downward,  keeping  as  close  to  the  bone  as  possible.     The  flaps 


376  OPERATIVE    SURGERY 

are  retracted  and  both  malleoli  together  with  a  very  thin  slice  of  the  tibia 
are  removed  Avith  a  saw.  The  posterior  or  heel  flap  is  brought  forAvard  and 
sutured  so  that  it  will  bear  all  the  pressure  on  the  stump. 

If  the  SA-me  amputation  cannot  be  done  the  next  point  of  amputation 
should  be  on  the  leg  about  four  inches  above  the  ankle  joint,  because  of  the 
difficulty  of  fitting  an  artificial  leg  or  foot  at  a  point  closer  to  the  ankle 
joint.  This  may  be  done  by  flaps  or  by  the  oval  method.  A  long  posterior 
and  a  short  anterior  flap  make  an  excellent  stump.  If  the  long  posterior 
flap  is  taken  it  should  be  more  from  the  posterointernal  aspect  than  from 
a  strictly  po.sterior  surface.  The  incision  begins  on  the  inner  side  of  the 
tibia  and  is  carried  down  below  the  sawline  for  a  distance  about  equal  to 
one  and  one-fourth  diameters  of  the  limb.  It  then  goes  back  across  the  leg 
and  upward  to  a  point  opposite  its  beginning.  The  anteroexternal  flap 
is  formed  by  an  incision  which  goes  forward  and  slightly  downward  half- 
way around  the  leg  and  is  so  placed  as  to  make  the  short  flap  about  one-third 
to  dne-ha1f  the  length  of  the  long  flap.  The  incisions  are  carried  through  the  skin 
and  fascia  and  are  then  deepened  to  the  bone.  The  flaps  are  retracted  above 
the  level  of  the  saw  line  and  the  bone  is  divided.  The  crest  of  the  tibia, 
which  is  sharp,  is  beveled  so  as  to  prevent  pressure.  The  periosteum  and  en- 
dosteum  are  removed  and  the  nerves  treated  as  has  been  described*  in  ampu- 
tations of  the  arm.  In  amputations  of  the  lower  extremity  the  stump  must 
bear  great  strain  and  weight.  Eemoval  of  the  periosteum  and  endosteum, 
as  has  been  described  in  the  general  remarks  on  amputation  of  the  upper 
extremity,  together  with  the  treatment  of  the  nerves  in  the  stump  is,  for 
these  reasons,  particularly  appropriate  here.  The  tendo  Achillis  and  the 
muscular  structure  in  its  neighborhood  are  brought  forward  and  sutured 
across  the  bone  to  the  tendons  and  muscles  of  the  anterior  portion  of  the 
leg.  The  long  flap  is  so  sutured  to  the  short  flap  that  the  scar  will  not  lie 
over  the  end  of  the  bone,  but  will  be  anterior.  This  is  u.sually  called  Fara- 
beuf's  operation. 

In  the  middle  third  of  the  leg  a  long  posterior  and  a  short  anterior  flap 
amputation  is  excellent  (Fig.  378).  This  is  called  Key's  operation.  The  circu- 
lar or  oblique  method  or  equilateral  flaps  may  be  used.  In  amputation  through 
the  middle  or  the  upper  third  of  the  leg  the  flbula  should  be  cut  about 
one-half  inch  shorter  than  the  tibia.  Through  the  upper  third  of  the  leg  some 
operators  prefer  to  disarticulate  the  fibula  entirely.  In  making  the  incis- 
ion for  amputation  through  the  middle  third  of  the  leg  by  a  long  poste- 
rior and  a  short  anterior  flap  the  posterior  flap  should  be  broad  and 
U-shaped,  its  breadth  being  equal  to  one-half  the  circumference  of  the  limb  at 
the  saAv  line  and  its  length  equal  to  one-third  of  this  circumference.  The 
incision  begins  one  inch  below  the  saw  line,  is  carried  doAvn  the  leg  just 
behind  the  inner  border  of  the  tibia,  and  curves  back^vard  broadly  on  the  back 
of  the  ie^.  The  outer  incision  passes  doAvuAvard  just  liehind  the  fibula  and 
back  of  the  peroneus  muscles  and  cur^-es  onto  the  back  of  the  leg.  uniting 
with  the  inner  incision.  The  anterior  flap  is  one-third  the  length  of  the  pos- 


TIIK    LOWER    KXTKKMITY 


377 


terior  Ihip  and  is  foniu'd  by  joiniiiu'  llu'  N'ciiical  iiu'isioiis  lo  I'oi'iii  tlie  pos- 
terior llap  about  llu>  jimctiou  of  tludr  middle  and  n])p('r  Ihii'ds  l)y  an  incision 
across  the  front  of  the  leg',  which  curves  slightly  downward.  These  incisions 
are  made  while  the  knee  is  flexed.  The  incision  is  carried  dowii  through 
the  skin  and  fascia  and  the  posterior  muscles  are  cut  while  tlie  Haps  are 
retracted.  The  vertical  incisions  are  deepened  and  the  anterior  muscles 
are  divided.  The  muscles  are  detached  from  the  bone  and  the  interosse- 
ous membrane  above  and  the  interosseous  membrane  is  divided.  The  perios- 
teum is  removed  either  before  or  after  the  bone  is  sawed.  The  endosteum 
is  removed.  The  crest  of  the  tibia  is  beveled.  The  nerves  are  treated  as 
usual  and  the  muscles  are  carefully  sutured  over  the  ends  of  the  bones  as 
there  is  a  tendency  for  the  posterior  muscles  to  pull  backward.  The  skin  flap 
is   sutured   in   the   usual  way. 


Fig.    378. — Lines   of   incision   for  amputation   of   leg:   A,   Hey;    B,    Stephen    Smith 


Amputation  through  the  upper  third  of  the  leg  may  be  made  by  a  large 
external  flap  according  to  the  method  of  Farabeuf,  or  by  a  bilateral  hooded 
flap  according  to  the  method  of  Stephen  Smith.  In  the  operation  of  Farabeuf 
a  U-shaped  flap,  whose  length  is  equal  to  the  diameter  of  the  leg  at  the  saw 
line  is  outlined  by  beginning  the  incision  about  opposite  the  saw  line  in  front, 
carrying  it  down  just  internal  to  the  crest  of  the  tibia  and  curving  across  the 
outer  portion  of  the  leg  (Fig.  379).  The  incision  then  passes  vertically  up- 
ward opposite  the  anterior  incision  but  terminates  about  one  and  one-half 
inches  below  the  saw  line.  The  transverse  incision  is  carried  across  the 
inner  aspect  of  the  leg,  curves  slightly  downward,  and  unites  the  upper  end 
of  the  posterior  incision  with  a  point  on  the  anterior  incision  about  one  and 
one-half  inches  below  its  beginning.  The  external  flap  is  dissected  up  along 
the  lines  of  the  retracted  skin  and  fascia,  carrying  the  incision  to  the  bone. 


378 


OPERATIVE    SURGERY 


The  anterior  incision  is  deepened  to  the  anterior  border  of  the  tibia  and  the 
tibialis  anticns  is  freed  from  the  bone.  The  entire  mnsele  mass  is  separated 
from  the  tibia,  the  interosseous  membrane,  and  the  fibula  by  knife  and  ele- 
vator. It  is  important  not  to  injure  the  anterior  tibial  artery  after  it  has 
been  severed  at  the  end  of  the  flap.  If  the  flap  is  dissected  too  high  behind 
where  the  vertical  incision  is  short  the  anterior  tibial  artery  may  be  cut  be- 
fore it  penetrates  the  interosseous  membrane.  The  transverse  incision  is 
carried  down  on  the  line  of  the  retracted  skin  and  fascia  and  the  interosseous 
membrane  is  divided.  The  periosteum  is  divided  and  dissected  down  about 
one-half  inch  above  the  saw  line  and  the  bones  are  divided  after  retracting- 


Fig.  379. — lyines  of  incision  for  amputation  of 
leg:  A,  Farabeuf;  B,  amputation  by  modified  cir- 
cular   method. 


Fig.    380. — Lines    of    incision    for    amputation    oi 
Stephen  Smith  'at  the  knee  joint. 


the  soft  parts.  The  crest  of  the  tibia  is  beveled  and  the  endosteum  at  the  end 
of  the  sawed  bone  is  removed.  The  fibula  is  sawed  about  one-half  inch  higher 
than  the  tibia.  The  nerve  trunks  and  vessels  are  treated  in  the  usual  way 
and  the  muscle  flaps  are  sutured  together  over  the  ends  of  the  bones.  The 
edges  of  the  external  flap  are  sutured  to  the  transverse  internal  incision. 

Amputation  through  the  middle  or  upper  portion  of  the  leg  should  be 
followed  by  the  application  of  a  posterior  splint  in  order  to  prevent  flexion 
of  the  stump. 

Amputation  through  the  upper  third  of  the  leg  may  also  be  done  by  the 
bilateral  hooded  method  of  Stephen  Smith  (Fig.  378).  As  has  already  been 
stated,  however,  the  amputation  should  not  be  made  too  near  the  joint  as  too 


THE    LOWKH    KXTRKMITY  379 

short  a  sluiiii)  iiialvos  it  imi)()ssi))le  to  fit  an  arlilicial  leg  satisfactorily.  The 
surgeon  grasps  the  leg  so  as  to  mark  the  upper  limit  of  the  anterior  incision 
with  his  left  thumb  about  three-fourths  of  the  diameter  of  the  leg  below  the 
saw  line  on  the  anterior  border  of  the  tibia  and  the  upper  extremity  of  the  po:;- 
terior  iiieision  by  his  left  index  finger  about  opposite  the  saw  line  of  the  bone. 
lie  begins  by  incising  the  posterior  tissue  at  the  tip  of  the  index  finger,  then 
cuts  downward  and  curves  the  incision  gradually  to  the  side  of  the  leg,  carry- 
ing it  curving  slightly  upward  to  the  end  marked  by  his  thumb.  A  similar 
incision  is  repeated  on  the  other  side  of  the  leg,  except  that  the  flap  is  made 
a  little  larger  on  the  inner  side  than  on  the  outer.  The  flaps  of  skin  and  fascia 
are  dissected  up  for  about  an  inch  and  are  retracted  and  the  muscles  are  di- 
vided in  a  circular  manner  to  the  bone.  The  interosseous  membrane  is  divided 
and  the  bone  is  sawed  across  as  in  the  operation  of  Farabeuf.  The  muscles  are 
sutured  across  the  stump  of  the  bone  and  the  skin  is  closed  in  the  usual  manner. 

Amputation  or  disarticulation  at  the  knee  may  be  done  by  the  bilateral 
hooded  method  of  Stephen  Smith  (Fig.  380),  though  an  elliptical  or  oblique 
circular  incision,  or  a  long  anterior  flap  may  be  employed.  The  operation  of 
Stephen  Smith  at  the  knee  joint  is  similar  to  that  of  Stephen  Smith  in  the 
upper  third  of  the  leg.  The  original  technic  calls  for  a  covering  of  only 
skin  and  fascia,  but  this  can  sometimes  be  advantageously  modified  by 
first  dissecting  the  lower  ends  of  the  flap  for  about  an  inch  and  then  dividing 
the  muscles  and  soft  parts  by  a  circular  incision  and  retracting  these  struc- 
tures to  the  joint.  The  incision  begins  behind,  in  the  midline,  at  a  point  about 
opposite  the  line  of  the  knee  joint  in  the  midpopliteal  space  and  is  carried 
downward  vertically  for  about  two  inches,  then  gradually  downward  and 
forward  over  the  outer  part  of  the  leg,  and  finally  upward,  ending  at  a  point 
about  one  inch  below  the  tibial  tubercle.  The  internal  flap  is  similar,  but  is 
slightly  larger  to  cover  the  larger  internal  femoral  condyle.  The  tissues  are 
dissected  for  about  an  inch  and  the  muscles  and  soft  tissues  are  divided  to  the 
bone  and  retracted  to  the  level  of  the  joint.  As  much  of  the  capsule  of  the 
joint  is  included  as  possible.  The  semilunar  cartilages  are  kept  with  the 
ligaments  of  the  joint  so  as  to  afford  greater  protection  to  the  condyles.  The 
joint  is  entered  between  the  head  of  the  tibia  and  the  semilunar  cartilage. 
The  knee  is  then  flexed  and  the  crucial  ligaments  are  divided.  The  knee  is 
extended  and  the  other  ligaments  holding  the  knee  are  severed.  The  vessels 
and  nerves  are  treated  in  the  usual  way  and  the  flaps  so  sutured  that  the 
scar  is  posterior  and  in  the  intercondyloid  notch. 

This  operation  is  an  excellent  one  for  amputation  through  the  knee,  par- 
ticularly in  the  old  when  the  amputation  is  done  for  gangrene  of  the  foot.  It 
makes  a  broad  stump  which  bears  well,  but  it  is  objectionable  because  the 
broadness  of  the  stump  makes  it  difficult  to  fit  an  artificial  leg  and  because 
the  joint  of  the  artificial  leg  has  to  be  at  a  lower  level  than  the  normal  joint. 

In  amputating  through  the  thigh  as  much  stump  as  possible  should  be 
saved  on  account  of  the  leverage.  Most  of  the  weight  of  an  artificial  limb  is 
borne  not  on  the  end  of  the  stump  but  on  other  portions  of  the  stump  and  on 


380  OPERATIVE    SURGERY 

the  tuberosity  of  the  i.sciiium.  A  finu,  painless  stump,  however,  is  most 
desirable.  As  a  rule,  a  long  anterior  and  short  posterior  flap  amputation  is 
preferable.  The  retraction  is  greater  on  the  posterior  and  inner  part  of 
the  thigh  than  elsewhere,  so  allowance  must  be  made  for  this,  and  it  should 
also  be  borne  in  mind  that  the  lower  the  amputation  the  greater  the  retraction. 
The  circular  method  of  amputation  in  the  thigh,  however,  often  gives  very 
satisfactory  results,  though  the  advantage  of  the  long  anterior  flap  is  that  it 
drops  over  the  end  of  the  bone  and  does  not  permit  the  tissue  to  sag  back  as 
with  equal  flaps  or  a  long  posterior  flap. 

Above  the  knee  the  most  satisfactory  amputation  close  to  the  knee  is 
not  the  transcondyloid,  but  the  supracondyloid  operation,  or  the  Gritti-Stokes, 
in  which  a  long  anterior  and  a  short  posterior  flap  are  employed.  The  trans- 
condyloid operation  is  unsatisfactory  from  the  standpoint  of  fitting  an  arti- 
ficial leg.  In  the  supracondyloid  amputation,  or  the  Gritti-Stokes,  the  operation 
is  so  planned  that  the  division  of  the  femur  is  made  about  three-fourths  to 
one  inch  above  the  adductor  tubercle,  so  the  patella  can  be  applied  to  a  trans- 
verse section  of  bone  about  its  size  (Fig.  381). 

The  incision  for  a  long  anterior  flap  in  this  operation  begins  one  inch 
above  the  prominence  of  tlie  internal  condyle  and  is  carried  downward  and 
slightly  forward  making  a  broad  curve  and  crossing  the  upper  part  of  the  leg 
just  below  the  tubercle  of  the  tibia.  It  curves  upward  and  outward  to  a 
point  one  inch  above  the  external  condyle.  The  incision  for  the  posterior 
flap,  which  is  shorter  than  the  anterior  flap,  begins  at  the  upper  portion  of  the 
incision  for  the  anterior  flap,  curves  backward  and  downward,  ending  at  the 
corresponding  point  on  the  opposite  side  of  the  leg.  It  is  so  fashioned  that 
the  posterior  flap  is  about  one-third  the  length  of  the  anterior  flap.  These 
flaps  are  dissected  upward  and  the  skin  and  fascia  of  the  anterior  flap  are 
freed  until  the  ligamentum  patellae  is  reached,  which  is  divided  and  wdth  the 
patella  turned  up  with  the  anterior  flap.  The  posterior  flap  is  dissected  up 
and  consists  solely  of  the  skin  and  fascia.  Both  flaps  are  retracted  to  the 
saw  line,  which  is  about  three-fourths  to  one  inch  above  the  adductor  tuber- 
cle and  all  tissues  are  divided  to  the  bone  by  a  circular  incision.  The  perios- 
teum here  is  not  removed  as  in  the  usual  amputation.  The  bone  is  sawed. 
After  the  vessels  and  nerves  have  been  treated  in  the  usual  way  the  patella 
is  seized  with  a  heavy  forceps  and  its  articular  surface  is  sawed  away  or  re- 
moved with  bone  forceps  The  denuded  surface  of  the  patella  is  applied  to 
the  stump  of  the  femur.  It  may  be  held  in  position  by  splinters  or  pegs  of 
bone  taken  from  the  end  of  the  femur  and  driven  through  holes  that  have  been 
drilled  through  the  patella  into  the  end  of  the  femur,  or  it  may  be  fastened  by 
two  stout  kangaroo  tendon  sutures  passed  through  drill  holes  in  the  patella 
and  in  the  end  of  the  femur.  If  there  is  too  much  forward  pull  of  the  ten- 
don of  the  quadriceps  the  tendon  may  be  partially  divided.  The  periosteum 
and  the  tissues  about  the  femur  are  fastened  to  similar  tissue  over  the  patella 
and  the  anterior  and  posterior  flaps  are  sutured  together  in  the  usual  manner. 

Amputation  through  the  lower  third  of  the  thigh  may  be  done  by  a  long 


THE   LOWER   EXTREMITY 


381 


;iii1(.M'iui'  aiitl  a  slioi'l  post ciMdf  llap,  or  l)y  the  cii'cular  oi'  ol)li(iiie  circular 
mctliod,  or  by  ('({iial  Haps,  I'oi-  soiiict  iiiics  on  accoiiiil  of  the  cliaradcr  of  the  injury 
one  of  these  methods  may  be  necessary  to  secure  satisfactory  flaps  (Fig.  382). 
Probably  the  best  method  for  amputation  of  the  thigh  anywhere,  except  in 
immediate  proximity  to  the  joint,  is  by  a  long  anterior  and  a  short  posterior 
Jla]>.  Tlu>  length  of  the  anterior  flap  is  equal  to  one  and  one-half  times  the 
diameter  of  the  thigh  at  the  saw  line  and  its  breadth  is  slightly  greater.  The 
incision  begins  opposite  the  saw  line,  about  the  middle  of  the  inner  surface  of 
the  thigh,  and  passes  down  the  iinier  portion  of  the  thigh,  curving  forward 


Fig.  381. — Lines  of  incision  for  amputation  of 
the  thigh:  A,  by  long  anterior  and  short  poste- 
rior flaps;  B,  by  the  method  of  Gritti-Stokes; 
C,   by   lyister's   modification    of   Garden's   operation. 


Fig,  382. — A,  lines  of  incision  for  amputation 
of  the  hip  joint  by  the  method  of  Wyeth.  (The 
external  racket  incision.)  B,  lines  of  incision  for 
amputation  of  the  thigh  by  modified  circular 
method. 


broadly  over  the  anterior  surface  to  a  distance  below  the  saw  line  equal  to 
about  one  and  one-half  times  the  diameter  of  the  thigh  at  the  saw  line.  (Fig. 
381.)  It  then  broadly  curves  upward  on  the  outer  portion  of  the  thigh  to  a  point 
about  opposite  its  beginning.  The  incision  for  the  posterior  flap  begins  at  the 
upper  end  of  the  incision  for  the  anterior  flap  and  is  carried  over  the  posterior 
portion  of  the  leg,  curving  so  that  the  posterior  flap  is  only  about  one-third 
as  long  as  the  anterior  flap.  Because  of  the  great  amount  of  retraction  it  is 
well  to  make  generous  allowance  for  flaps  in  amputation  of  the  thigh.  After 
the  skin  and  fascia  of  the  anterior  flap  have  retracted  the  muscles  under  this 


382 


OPERATIVE   SURGERY 


flap  are  divided  obliquely  from  -without  inward,  forming  a  flap  of  the  muscles 
of  the  anterior  portion  of  the  leg.  The  dissection  is  carried  through  the  mus- 
cle down  to  the  level  of  the  saw  line  in  an  oblique  manner.  The  thigh  is 
raised  and  the  posterior  flap  is  dissected  and  a  short  flap  of  muscle  is  made 
by  cutting  the  muscle  obliquely  from  the  surface  down  to  the  bone  as  in  the 
anterior  flap.  In  this  way  the  anterior  and  the  posterior  flaps  consist  of  bev- 
eled tissue  with  the  sharp  edge  downward  and  the  l)ase  al)0ut  the  level  of 
the  saw  line  of  the  bone.  The  muscles  are  fully  divided  down  to  the  bone  and  are 
retracted.  The  periosteum  is  removed  from  the  bone  for  about  half  an  inch 
above  the  saw  line  and  the  bone  is  sawed.  The  endosteum  is  removed  and  the 
irregularities  on  the  end  of  the  bone  are  treated  in  the  usual  manner,  partic- 
ular care  being  taken  to  smooth  the  bone  along  the  line  of  the  linea  aspera. 


Fig.   383. — The   method   of   Wyelh   for   hemostasis   in   amputation   at   the   hip  joint. 


The  nerves  and  vessels  are  treated  in  the  usual  manner  and  the  muscles  in  the 
anterior  flap  are  sutured  to  the  muscles  in  the  posterior  flap  Avith  heavy  mat- 
tress sutures  of  catgut.  The  fascia  is  also  approximated  and  the  skin  flaps 
are  closed  in  the  usual  manner. 

Amputation  just  below  the  trochanters  may  be  done  by  the  external  oval 
method,  or  by  the  racket  incision,  which  is  used  in  amputation  at  the  hip 
joint.  The  incision  begins  over  the  great  trochanter  in  the  outer  portion  of 
the  thigh,  is  carried  down  the  outer  portion  of  the  thigh  for  about  four  inches, 
then  anteriorly  along  the  front,  and  then  across  the  inner  aspect  of  the  thigh 
in  an  oval  manner.  The  posterior  incision  begins  about  four  inches  below  the 
point  of  beginning  of  the  vertical  incision  and  passes  downward  and  backward, 
meeting  the  anterior  incision  on  the  back  of  the  thigh  at  a  point  about  six 
inches  below  the  level  of  the  trochanter  major.  The  skin  and  fascia  are 
dissected  up  for  about  two  inches  along  the  lines  of  the  incision  and  the  shaft 


THE    I.OWER    EXTREMITY 


383 


of  the  bone  is  exposed  tlirnuph  the  vertical  incision.  Tlie  muscles  are  then 
divided  by  a  circular  cut  on  a  line  with  the  retracted  flap.  The  soft  tissues 
are  retracted  and  the  femur  is  sawed  just  l)elow  the  trochanter.  The  muscles 
are  sutured  together  with  mattress  sutures  of  catgut  and  the  skin  flap  is 
sutured  in  a  liorizontal  line  from  within  outAvard. 

The  great  problem  of  amputation  at  tlie  hip  joint  has  been  the  control  of 
hemorrhage.  In  individuals  who  are  thin  and  where  there  is  much  disease 
about  the  hip  joint  this  can  be  done  by  an  anterior  racket  incision,  which  first 
exposes  the  femoral  vessels  so  they  may  be  controlled  and  divided  in  the  early 
stage  of  the  operation.  With  careful  dissection  the  bleeding  points  may  be 
clamped  as  they  are  reached  and  but  little  blood  is  lost.  When,  however, 
there  is  no  pathology  at  the  level  of  the  hip  joint  which  may  be  adversely 
affected  by  the  tourniquet,  or  when  the  patient  is  large  and  muscular  the 
bleeding  should  be  controlled  by  the  application  of  a  rubber  tourniquet  ac- 
cording to  the  method  of  Wyeth  (Fig.  383).  In  this  method  pins  or  mattress 
needles  about  two-sixteenths  to  three-sixteenths  of  an  inch  in  diameter  and 
ten  inches  long  are  inserted  through  the  thigh.  One  pin,  entering  the  outer 
portion  of  the  thigh  just  below  and  to  the  inner  side  of  the  anterior  superior 
iliac  spine,  passes  through  the  superficial  muscles  and  fascia  on  the  outer  side 
of  the  hip  and  emerges  about  three  inches  from,  and  on  the  same  level  with, 
its  point  of  entrance.  The  second  pin  is  introduced  on  the  inner  portion  of  the 
thigh  about  one-half  inch  below  the  perineum  and  internal  to  the  saphenous 
opening.  It  traverses  the  adductor  muscles  and  emerges  about  one  inch  below 
the  tuberosity  of  the  ischium.  Sterile  corks  are  placed  on  the  sharp  ends  of 
the  pins  or  mattress  needles  to  prevent  injury  to  the  hand  of  the  operator.  A 
small  compress  of  gauze  is  placed  over  the  femoral  artery  and  rubber  tubing 
about  one-third  of  an  inch  in  diameter  is  "s^Tapped  tightly  four  or  five  times 
around  the  thigh  just  above  the  needles  and  is  fastened  by  tying  the  ends  with 
a  bandage  and  by  clamping  them  with  pedicle  forceps.  A  circular  incision  is 
made  around  the  thigh  about  six  inches  below  the  anterior  part  of  the  tourniquet 
and  then  a  vertical  incision  begins  above  the  great  trochanter  just  below  the 
tourniquet  and  passes  downward,  joining  the  circular  incision.  The  circular 
incision  goes  only  through  the  skin  and  fascia,  which  are  dissected  to  the 
level  of  the  lesser  trochanter  about  two  inches  (Fig.  382-A).  Here  the  mus- 
cles are  divided  to  the  bone  by  a  circular  incision  and  the  vertical  incision 
which  has  previously  been  made  is  deepened  to  the  bone.  The  large  vessels 
are  then  clamped  and  tied.  Through  the  vertical  incision  which  is  carried 
to  the  bone  the  tissues  are  separated  from  the  shaft  and  tuberosity  of  the 
femur  and  the  soft  parts  are  retracted.  The  muscular  attachments  to  the 
trochanter  are  divided  with  scissors  while  the  limb  is  rotated  alternately  in- 
ward and  outward.  The  capsular  ligament  is  divided  at  its  outer  front  border 
and  the  cotyloid  ligament  is  incised  to  let  in  the  air  and  overcome  the  suction 
of  the  joint.  The  posterior  portion  of  the  capsule  is  divided.  The  head  of  the 
femur  is  then  twisted  out  of  position  by  rotating  the  thigh.  If  this  proveT 
in  anv  way  difficult,  which  is  unusual,  the  margin  of  the  acetabulum  may  be 


384 


OPERATIVE    SURGERY 


chipped  away  with  a  chisel  to  let  in  the  air,  or  if  the  vessels  have  been  caup'ht  and 
tied  the  toni'ni(piet  may  be  removed  and  the  disarticnlation  c(mipleted.  After  ty- 
ing all  the  vessels  that  can  be  found  the  tonrniqnet  is  loosened  to  see  if  any  ves- 
sels have  been  overlooked.  The  muscles  are  approximated  by  mattress  sutures 
of  stout  catgut.  Drainage  by  a  rubber  tube  carried  to  the  acetabulum  is  estab- 
lished, the  tube  being  removed  in  forty-eight  hours.  The  skin  wound  is  sutured 
from  within  outward,  making  a  continuous  line.  An  abundant  dressing  is  ap- 
plied with  firm  compression. 

If,  because  of  the  pathology  about  the  hip  joint,  or  the  thinness  of  the  pa- 
tient, it  is  advisable  not  to  use  a  tourniquet,  the  anterior  racket  method  is 
satisfactory.  The  method  of  Wyeth  is  an  external  racket  incision.  The  ante- 
rior racket  incision  begins  about  the  center  of  Poupart's  ligament  and  passes 


Fig.  384. — Lines  of  incision   for  amputa'.ion   at  the   liip  joint  by  the  anterior   racket  incision. 


down  over  the  femoral  artery  for  three  inches,  then  curves  inward  and  crosses 
the  inner  portion  of  the  thigh  about  four  inches  below  the  perineum  (Fig.  384). 
From  this  point  it  is  carried  across  the  posterior  and  outer  aspect  of  the  thigh 
a  short  distance  below  the  great  trochanter,  and  then  curves  upward  and  in- 
ward to  join  the  lower  end  of  the  vertical  incision  two  inches  below  Poupart's 
ligament.  Through  the  vertical  portion  of  the  incision  the  femoral  artery  and 
vein  are  exposed,  carefully  ligated,  and  divided.  Two  ligatures  at  distances 
of  about  one-fourth  to  one-half  an  inch  are  placed  upon  the  femoral  artery,  as 
has  been  insisted  upon  in  the  general  description  of  amputations.  This  is 
particularly  important  here  because  of  the  large  size  of  the  vessel  and  the 
great  pressure  within  its  lumen.  The  skin  and  fascia  are  freely  dissected  along 
the  entire  incision  and  the  muscles  on  the  outer  side  of  the  thigh  are  divided, 
the  external  circumflex  artery  being  doubly  clamped  and  tied.     The  thigh  is 


TUI',    LOWICR    EXTREMITY  385 

elevated  aiul  the  dissect  ion  is  carried  l)aclx\var(l,  dividing'  tlie  insertion  of  the 
giuteus  maxinms  muscle.  The  thigh  is  tlieii  i-otated  and  the  muscles  on  the 
posterior  and  inner  portion  of  the  thigh  are  divided.  Carefully  clamping  the 
bleeding  points  and  searching  if  possible  for  the  internal  circumflex  artery, 
the  muscles  in  the  internal  portion  of  the  thigh  are  divided  on  a  level  with  the 
retracted  shin.  Tlie  tliigli  is  adducted  and  rotated  imvard  and  the  mus- 
cles attached  to  the  great  trochanter  are  severed.  The  femur  is  then  adducted 
and  rotated  outward  and  the  capsule  cut  and  any  tendons  that  have  not  been 
divided  are  severed.  The  capsule  is  divided  with  a  long  knife  or  with  curved 
scissors.  The  muscles  and  skin  are  sutured  together  as  after  the  amputation 
by  Wyeth's  method,  except,  of  course,  the  line  of  sutures  runs  from  before 
backward  instead  of  from  within  outward,  as  with  Wyeth's  method.  By  a 
careful  technic  this  incision  by  the  anterior  racket  method  in  suitable  cases 
can  be  carried  through  with  but  little  loss  of  blood. 

TENDONS  AND  MUSCLES 

The  three  types  of  operations  on  tendons  are  lengthening  a  tendon,  short- 
ening a  tendon,  and  transplanting  of  tendon  and  muscle  from  its  normal  inser- 
tion to  another  position  to  take  the  place  of  a  paralyzed  or  weakened  muscle 
and  to  produce  a  proper  balance  between  the  flexors  and  extensors  of  a  jonit. 

Tenotomy  may  be  open  or  subcutaneous.  The  regeneration  of  a  tendon 
is  practically  perfect,  particularly  of  such  a  tendon  as  the  tendo  Achillis. 
This  regeneration  is  facilitated  by  the  presence  of  a  part  of  the  tendon 
sheath,  so  it  is  important  not  to  divide  completely  the  whole  of  the  ten- 
don sheath  in  doing  a  tenotomy,  for  if  it  is  cut  entirely  across,  this  portion 
of  the  repaired  tendon  may  become  adherent  and  composed  largely  of  scar 
tissue  that  does  not  blend  readily  with  the  normal  tendon.  Subcutaneous 
tenotomy  should  not  be  done  where  there  are  important  blood  vessels  or  nerves 
that  might  be  accidentally  injured. 

If  the  open  operation  for  tenotomy  is  done  the  skin  and  subcutaneous  fat 
over  the  tendon  are  incised,  the  sheath  of  the  tendon  is  opened  and  the  tendon 
split  in  its  middle  for  a  half  inch,  separating  its  fibers  vertically.  At  one 
extremity  of  the  incision  half  of  the  tendon  is  cut  across  at  a  right  angle  to 
the  slit  and  at  the  other  extremity  of  the  slit  the  other  half  on  the  opposite 
side  is  divided.  In  this  manner  the  tendon  resembles  a  step  and  the  ends  may 
be  sutured  together  or  left  free.  The  open  operation  is  sometimes  done  by 
cutting  the  tendon  diagonally  from  side  to  side.  If  it  is  sutured,  fine  tanned 
or  chromic  catgut  or  silk  is  used.  The  incision  in  the  skin  is  made  some- 
what to  one  side  of  the  prominent  line  of  the  tendon  so  that  the  scar  in 
the  skin  will  not  fall  on  the  most  prominent  position.  The  tendon  should  be 
handled  carefully  and  should  not  be  clamped  unless  it  is  intended  to  cut  away 
the  portion  that  is  clamped. 

In  subcutaneous  tenotomy,  such  as  tenotoni}^  of  the  tendo  Achillis,  the 
tendon  is  divided  by  the  insertion  of  a  small  sharp-pointed  tenatome  through 


386 


OPERATIVE    SURGERY 


the  skin  beside  and  beneath  the  tendon.  This  is  done  from  the  inner  side 
of  the  leg  when  the  tendo  Achillis  is  divided,  which  is  the  usual  structure  on 
which  this  operation  is  done.  After  puncturing  the  skin  it  is  safer  to  use  a 
dull  pointed  tenatome  passed  beneath  the  tendon.  The  blade  is  then  turned 
so  that  the  cutting  edge  faces  the  tendon  and  the  foot  is  strongly  flexed  dor- 
sally.  This  makes  the  tendon  very  tense.  It  is  divided  by  a  sawing  motion, 
care  being  taken  not  to  cut  the  skin.  "When  the  fibers  are  completely  divided 
it  gives  way  with  a  popping  sound  and  the  heel  is  immediately  lowered. 
There  need  be  no  fear  that  the  tendo  Achillis  will  fail  to  unite  after  a 
properly  done  tenotomy,  for  in  large  clinics  wdiere  thousands  of  these  opera- 
tions are  performed  lack  of  union  is  almost  never  seen  and  is  then  probably 


Fig.    385. 


-Open    tenotomy   by    the    zigzag   or    step 
method. 


Fig.  386. — Points  of  -entrance  of  the  tenotome 
in  subcutaneous  tenotomy  of  the  plantar  fascia. 
(Soutter.) 


due  to  the  fact  that  the  sheath  of  the  tendon  has  been  completely  divided.  By 
keeping  close  to  the  tendon  and  using  a  blunt-pointed  tenatome  after  the 
initial  puncture  there  is  but  little  danger  of  total  division  of  the  sheath. 

Open  tenotomy  is  sometimes  used  for  relief  of  contraction  of  the  flexor 
longus  digitorum.  Here  an  incision  about  tw^o  inches  long  is  made  half 
an  inch  back  of  the  internal  malleolus  through  the  skin  and  fat.  The  ten- 
dons of  the  flexor  longus  digitorum  are  exposed  and  pulled  upon  to  assure 
the  surgeon  that  they  are  connected  with  the  toes.  The  tendons  may  be 
lengthened  by  the  step  method,  or  zig-zag  tenotomy  as  it  is  sometimes  called, 
or  by  an  oblique  incision  (Fig.  385).  They  are  then  sutured  with  fine  chromic 
or  tanned  catgut.     The  sheath  and  the  subcutaneous  tissues  are  brought  to- 


TlIK    LOWER    i:XTREMlTY  387 

gether  with  catgut  and  the  skin  is  closed.  Usually  skin  closures  over  a  tenot- 
omy or  transplantation  are  more  satisfactory  when  done  with  silkworm-gut 
than  with  catgut,  as  this  causes  less  reaction  in  the  skin. 

In  club  foot  operations  subcutaneous  tenotomy  of  the  plantar  fascia  is 
often  performed.  The  tenotome  has  a  narrow  blade  and  is  sharp-pointed.  The 
surgeon  holds  the  ball  of  the  foot  in  his  left  hand  and  inserts  the  tenotome 
perpendicularly  through  the  skin  at  the  inner  edge  of  the  tense  plantar  fascia 
and  between  the  skin  and  the  fascia  Avhich  is  demonstrated  by  flexing  the  foot 
dorsally  and  bringing  out  the  strong  contracting  bands.  The  fascia  is  divided 
in  various  directions  until  the  contracting  bands  are  all  severed.  Care  is 
exercised  not  to  cut  the  skin  for  the  wound  may  be  torn  in  subsequent  manip- 
ulations. The  deep  tendons  are  also  avoided.  If  all  the  bands  cannot  be 
reached  by  division  from  the  inner  edge  of  the  plantar  fascia  the  tenotome 
can  be  inserted  at  the  outer  edge  (Fig.  386). 

Contraction  of  the  tendons  of  the  tibialis  posticus  and  the  peroneus  mus- 
cles is  best  treated  by  open  tenotomy.  The  tendon  of  the  tibialis  anticus  may 
be  divided  subcutaneously  at  the  inner  side  of  the  foot.  It  may  be  brought 
into  prominence  by  adducting  and  pronating  the  foot. 

Tendons  are  shortened  in  different  ways.  If  the  tendon  extends  into  the 
muscle  it  may  be  shortened  over  the  belly  of  the  muscle  by  a  step  or  zig-zag 
incision,  as  described  in  open  tenotomy,  cutting  the  ends  of  the  tendon  to 
make  it  shorter  and  then  suturing  the  two  halves  together  laterally.  It  must 
be  recalled  that  any  suturing  of  tendons  should  be  of  the  mattress  type  or 
else  the  suture  should  be  quilted  in  because  the  ordinary  interrupted  suture 
placed  in  end-to-end  union  of  the  tendon  will  split  its  fibers  and  will  not 
hold.  If  it  is  desirable  to  secure  a  particularly  strong  union  and  if  the 
extra  bulk  is  not  objectionable,  the  ends  of  the  tendon  may  be  overlapped 
without  cutting  away  any  of  it  and  sutured  to  each  other  laterallj^  The 
amount  to  be  excised  is  judged  by  lifting  the  tendon  and  taking  a  fold,  if 
it  is  small,  until  an  idea  can  be  had  of  the  amount  necessary  to  be  removed. 

The  principles  of  transplantation  of  tendons  have  been  discussed  in  de- 
scribing tendon  operations  in  the  upper  extremity.  The  same  principles  apply 
in  the  lower  extremity,  except  that  the  tendons  and  tissues  are  more  powerful 
and  extra  care  should  be  taken  to  secure  the  sutures.  The  transplanted  ten- 
don should  be  sutured  with  medium  size  braided  silk  in  which  there  is  no 
antiseptic  to  irritate  the  tissues.  This  silk  is  sterilized  solely  by  heating.  It 
is  tested  with  the  hands  before  being  used  in  order  to  be  sure  that  there  are 
no  weak  spots.  If  it  is  clamped  at  its  ends  the  knot  must  be  so  tied  that  the 
clamped  portion  is  not  included  in  the  portion  of  the  silk  that  is  left  in  the 
tissues.  The  knot  is  tied  three  times  and  the  ends  should  be  just  long  enough 
to  be  tucked  singly  in  the  tissues  without  being  erect.  The  method  of  tendon 
suture  called  the  Frisch  suture  described  on  p.  362  is  excellent  when  uniting 
tendons  to  each  other  by  the  end-to-end  method.     If  a  tendon  is  to  be  trans- 


388  OPERATIVE    SURG]':RY 

planted  into  a  bone  or  periosteum  the  hraided  silk  is  quilted  into  it  for  a  dis- 
tance of  about  two  inches  above  the  end.  The  suture  is  started  at  the  end  of 
the  tendon  and  is  threaded  in  a  straiglit  needle,  usually  a  round  needle,  un- 
less there  is  considerable  scar  tissue  in  the  tendon.  It  is  passed  back  and  forth 
at  a  right  angle  to  the  fibers  and  at  short  intervals  for  about  five  insertions 
and  it  is  then  returned  in  a  similar  manner.  If  the  tendon  is  to  be  trans- 
planted into  the  periosteum,  one  end  of  the  braided  silk  is  threaded  into  a 
curved  needle  and  quilted  through  the  periosteum  three  times.  The  other  end 
of  the  silk  is  similarly  quilted  through  the  periosteum  and  the  end  is  tied. 
Sometimes  a  notch  or  a  groove  is  cut  in  the  bone  and  the  end  of  the  tendon 
is  buried  into  the  groove  and  sutured  to  the  periosteum  or  ligaments  in  the 
neighborhood.  If  the  bone  can  be  drilled  through  and  the  drill  opening  en- 
larged with  a  burr  the  tendon  can  sometimes  be  carried  through  the  hole  in 
the  bone  and  fastened  to  the  periosteum  on  the  opposite  side.  This  is  the 
technic  employed  in  the  operation  of  Sir  Robert  Jones  of  transplantation  of 
the  extensor  proprius  hallucis  to  the  head  of  the  first  metatarsal  bone.  An 
excellent  method  of  securing  the  end  of  a  transplanted  tendon  is  to  insert  it 
through  a  slit  in  the  paralj'zed  tendon  near  the  insertion  of  the  latter.  After 
pulling  the  transplanted  tendon  through  this  slit  it  is  fastened  with  sutures 
at  the  point  where  it  transfixes  the  paralyzed  tendon.  A  second  slit  is  then 
made  in  a  somewhat  different  direction  lower  down  and  the  end  of  the 
transplanted  tendon  is  also  brought  through  this  second  slit  and  fastened. 
In  this  manner  the  transplanted  tendon  is  brought  through  a  slit  made  in 
the  paralyzed  tendon  anteroposteriorly,  through  another  slit  made  laterally 
farther  down,  and  is  then  fastened  securely  with  sutures. 

Where  it  is  possible  to  do  so  it  is  well  to  transplant  the  tendon  sheath  along 
M'ith  the  tendon,  as  it  adds  additional  protection  and  promotes  the  nutrition 
of  the  tendon.  If,  however,  its  course  is  in  the  subcuticular  fat,  the  fat  will 
soon  form  a  sheath.  It  is  important  that  the  tunnel  be  abundantly  large, 
for  there  is  a  tendency  to  contraction  which  will  bind  and  cause  adhesions 
to  the  transplanted  tendon  if  the  tunnel  is  not  of  sufficient  size. 

Paralyzed  muscle  usually  has  a  greyish  or  greyish  pink  color,  but  healthy 
muscle  is  a  deep  red.  It  is  highly  important  that  the  healthy  and  paralyzed 
muscles  be  thoroughly  differentiated  before  any  operation  is  undertaken. 
This  may  be  done  by  electrical  reaction  and  sometimes  it  is  necessary  to 
have  the  services  of  a  neurologist  in  order  to  be  certain  that  the  motion 
that  exists  is  not  due  to  the  compensating  action  of  some  adjoining  muscle 
or  group  of  muscles.  The  so-called  trick  motions,  especially  after  paralysis 
due  to  nerve  injuries,  may  be  very  deceptive. 

In  all  tendon  transplantations  it  is  best  to  have  a  tourniquet  so  the 
operations  may  be  done  in  a  bloodless  manner.  The  Esmarch  bandage  is  first 
applied  from  the  toes  to  where  the  tourniquet  is  to  be  placed  so  as  to  make  the 
field  entirely  bloodless. 

In  all  transplantations  the  deformity  for  which  the  operation  is  done 
should  be  thoroughly  overcorrected  before  the  tendon  is  transplanted,  else 


THE   LOWER   EXTREMITY 


389 


the  tension  Avill  be  so  great  lliat  tlie  transplant  Avill  not  l)e  placed  in  a  favor- 
able condition  for  healing. 

When  the  tibialis  anticus  muscle  is  paralyzed,  which  is  common  after 
infantile  paralysis,  the  tendon  of  the  peroneus  muscle  may  be  transplanted  to 
give  dorsal  motion  to  the  foot.  The  incision,  according  to  the  Lange  method, 
begins  one  inch  above  and  half  an  inch  posterior  to  the  tip  of  the  external 


Fig.    387.— Transplantation    of    the    tendon    of    the    peroneus    muscle.      The    tendon    and    muscle    have 
been   freed  and   are  about  to   be   drawn   through  an   anterior   incision. 


Pier  388  — A  suture  is  inserted  in  the  tendon  according  to  the  method  of  Frisch,  a  tunnel  is  made 
from  the^dorsum  of  the  foot  to  the  upper  anterior  incision,  and  the  tendon  is  about  to  be  drawn  through 
the  tunnel.      (I.ange  method  after   Soutter.) 

malleolus  and  goes  upward  to  the  middle  of  the  leg  parallel  to  the  fibula.  The 
strong  fibrous  sheath  about  the  malleolus  is  not  opened  or  divided  as  this  will 
weaken  the  joint  unnecessarily.  If  the  peroneus  muscles  appear  to  be  vigor- 
ous and  of  deep  red  color  the  lower  end  of  the  incision  is  pulled  downward  by 
a  retractor  to  permit  access  to  the  tendon  below  the  lowest  point  of  the  incis- 
ion. Both  the  long  and  short  peroneus  muscles  may  be  transplanted  at  the 
same  time,  though  transplantation  of  the  long  peroneus  is  the  only  one  that 


390  OPERATIVE    SURGERY 

is  necessary.  The  peroneiis  tendon  is  cut  as  low  clown  as  possible  after  pulling 
it  up,  retracting  the  avouiuI  down,  and  catching  it  with  a  hemostat  as  Ioav 
down  in  the  wound  as  possible  (Fig.  387).  This  clamped  portion  of  the  tendon 
at  the  tip  should  always  be  cut  away  in  any  transplantation,  as  union  is  made 
much  better  if  this  bruised  portion  is  cleanly  cut  away.  The  muscles  are  dis- 
sected from  the  bone  with  a  sharp  scalpel  until  a  line  of  cleavage  is  reached  and 
then  dissection  may  be  continued  bluntly.  Care  must  be  taken  to  avoid  injuring 
the  branch  from  the  external  popliteal  nerve,  which  lies  near  the  bone  anterior 
to  the  peroneus  muscle.  Another  incision  is  made  about  two  inches  in 
length  over  the  anterior  middle  portion  of  the  leg  down  to  the  fibers  of  the 
tibialis  anticus  muscle.  A  tunnel  is  made  in  the  subcutaneous  fat  connecting 
the  two  incisions  at  the  upper  portion  of  the  long  incision  and  the  tendon  of  the 
peroneus  muscle  is  passed  through  this  tunnel.  The  tunnel  should  be  abun- 
danth'  wide   (Fig.  388).     Stout  braided  silk  is  quilted  into  the   tendon,   as 


Fig.   389. — The  tendon  of  the   peroneus  has  been  transplanted   and  sutured   into   the  tissue   over  the   dorsum 

of  the  foot.     (Soutter.) 

has  already  been  described,  after  cutting  off  its  clamped  end.  The  tips  of 
the  silk  ligature  are  clamped  and  a  tunnel  is  made  in  the  subcutaneous  fat 
down  to  the  front  of  the  midtarsus  region  (Fig.  389).  The  point  of  insertion 
into  the  tarsus  depends  upon  the  deformity.  If  the  tibialis  anticus  is  the  chief 
or  only  muscle  that  is  paralyzed  the  insertion  should  be  about  the  middle  of 
the  tarsus,  but  if  the  tibialis  anticus  has  some  power  the  insertion  may  be  a 
little  further  to  the  outer  side.  A  curved  incision  is  made  over  the  tarsus  and 
a  flap  is  formed  with  its  base  internal  which  will  overlie  the  point  at  which  the 
tendon  is  to  be  transplanted.  The  base  of  the  flap  should  be  abundantly  broad 
so  as  not  to  interfere  with  its  circulation.  The  tendon  is  then  carried  through 
the  tunnel  from  the  second  incision  to  the  tarsus  by  a  pedicle  forceps,  a  tendon 
carrier,  or  a  long  uterine  dressing  forceps.  Whatever  instrument  is  used  is 
inserted  from  below  upward  and  an  abundantly  large  tunnel  is  made  in  the 
subcutaneous  fat.  The  silk  is  then  quilted  into  the  periosteum  and  ligaments 
of  the  tarsus,  as  has  been  described  in  the  general  remarks  on  tendon  trans- 


THE   LOWER   EXTREMITY  391 

plantation,  by  threading  each  end  of  the  silk  into  a  curved  needle,  passing  it 
at  least  three  times  in  the  periosteum  and  ligaments  and  tying  the  ends 
three  times.  The  tension  should,  of  course,  be  properly  regulated  so  that  it 
is  certain  that  the  tendon  or  muscle  has  free  play  in  the  tunnel  and  will 
slide  easily  and  that  the  tendon  when  the  silk  is  tied  holds  the  foot  in  about 
the  desired  position  without  marked  tension.  After  tying  the  silk  the  other 
tendons  of  the  foot  that  have  been  retracted  are  permitted  to  cover  the  in- 
sertion of  the  silk,  the  deeper  tissues  are  closed  with  fine  tanned  or  chromic 
catgut,  and  the  skin  is  sutured  with  silkworm-gut.  The  leg  and  foot  are  held  in 
such  a  position  as  will  relax  the  transplanted  tendon  and  should  be  kept  strictly 
in  this  position  for  about  ten  days,  when  the  patient  may  be  permitted  on  a 
bed  rest,  but  the  foot  is  kept  quiet  for  six  weeks.  After  about  tM'o  months 
the  patient  can  walk  on  crutches  and  a  small  amount  of  weight  bearing  with 
plaster  of  Paris  holding  the  foot  in  position  is  permitted. 

Usually  in  this  transplantation  it  is  wise  to  weaken  the  opposing  muscle 
by  a  subcutaneous  tenotomy  of  the  tendo  Achillis. 

The  tibialis  posticus  can  also  be  transplanted  to  take  up  the  action  of 
the  paralyzed  tibialis  anticus.  Here  an  incision  is  made  parallel  to  the  tibia 
beginning  about  one  inch  above  and  one-half  inch  posterior  to  the  internal  mal- 
leolus and  extending  to  the  middle  of  the  leg.  The  tendon  of  the  tibialis  posticus 
is  isolated  and  distinguished  from  the  flexors  of  the  toe  by  pulling  on  the  ten- 
don and  noting  the  action  on  the  toes.  The  tendon  of  the  tibialis  posticus  is 
clamped  with  a  hemostat  as  far  down  as  possible,  divided,  and  the  tendon  and 
muscle  are  dissected  to  the  middle  of  the  leg.  The  end  of  the  tendon  is  quilted 
with  braided  silk,  an  incision  is  made  over  the  front  of  the  tibia  about  its  mid- 
dle, and  a  subcutaneous  tunnel  is  formed  connecting  the  two  incisions.  The 
tendon  and  muscle  of  the  tibialis  posticus  are  passed  through  this  tunnel  and 
the  tendon  is  inserted  in  the  tarsus  as  described  in  the  operation  of  transplant- 
ing the  peroneus.  The  flexor  longus  digitorum,  the  extensor  longus  hallucis,  or 
the  extensor  longus  digitorum  may  also  be  transplanted  for  a  weak  or  paralyzed 
tibialis  anticus. 

"When  the  peroneus  muscles  are  paralyzed  half  of  the  tendo  Achillis  may 
be  transplanted  forward.  The  incision  begins  half  way  between  the  outer 
malleolus  and  the  outer  edge  of  the  tendo  Achillis  and  is  carried  up  the  mid- 
dle of  the  leg  exposing  the  outer  portion  of  the  tendo  Achillis  with  its  mus- 
cle and  the  peroneus  muscle  and  tendon.  The  outer  half  of  the  tendo  Achillis 
is  divided  at  the  os  calcis,  split  up,  and  carried  forward  Avhere  it  is  attached 
to  the  peroneus  tendons  through  a  slit  in  these  tendons.  This  half  of  the 
Achilles  tendon  is  quilted  with  a  silk  suture  which  is  then  quilted  into  the 
peroneus  tendon;  or  it  may  be  held  in  position  by  chromic  or  tanned  catgut 
sutures  which  fasten  it  securely  to  the  peroneus  tendon  after  the  proper 
amount  of  tension  has  been  estimated. 

In  total  paralysis  of  the  tibialis  posticus  half  of  the  tendo  Achillis  may  be 
brought  forward  into  the  tendon  of  the  tibialis  posticus  in  the  inner  side  of  the 
leg  as  described  in  transplantation  of  half  of  it  in  the  peroneus. 


392 


OPERATWE    SURGERY 


p;g_  390. Transplantation  of  the  tendon  of  the  peroneus  longus  into  the  tendo  Achillis.     (Sir  Robert  Jones.) 


Fig.    391. — The   peroneus   tendon   is  divided   and   the   tendo    Achillis   is   being   split.      (Jones.) 

In  paralysis  of  the  extensor  of  the  great  toe_,  after  an  incision  is  made  in  the 
lower  anterior  third  of  the  leg  the  extensor  tendons  are  exposed,  and  the  extensor 
tendon  of  the  great  toe  is  isolated  and  sutured  into  a  slit  made  in  the  tendon 


THE    LOWER    EXTREMITY 


393 


of  tlie  tibialis  aiiticus.    Care  sliouUl  be  lalu'ii  not  to  make  the  tension  too  great 
as  "lianniu'i'"  toe  nii^iit  result. 

In  paralysis  of  the  calf  muscles,  which  results  in  talipes  calcaneus,  trans- 
plantation of  the  peroneus  longus  tendon  into  the  tendo  Achillis  has  given 
excellent  results  in  the  hands  of  Sir  Robert  Jones.  Here,  as  elsewhere,  the 
det'ormily  should  be  overcorrected  as  far  as  possible  before  transplantation 
of  the  tendon.  The  patient  is  placed  so  that  the  tendo  Achillis  is  uppermost 
and  an  incision  is  made  slightly  to  its  outer  side  and  extending  upward 
from  its  insertion  four  inches.  After  exposing  the  tendon  thoroughly  a 
second  incision  is  made  beginning  about  half  an  inch  above  the  lower  end 


Fig.    392. — The   peroneus   tendon   is   drawn   tlirough   the   slit   in   the   tendo   Acliillis.      (Jones.) 

of  the  first  incision  and  passing  beneath  the  external  malleolus  for  about 
two  and  one-half  inches  along  the  outer  portion  of  the  foot.  The  triangular 
flap  thus  made  is  dissected  up  and  the  peroneus  longus  tendon  is  exposed 
just  below  the  external  malleolus  (Fig.  390).  The  peroneus  brevis  tendon  lies 
just  external  to  the  tendo  Achillis  and  behind  the  tendon  of  the  peroneus 
longus  (Fig.  391).  The  peroneus  longus  tendon  is  isolated  and  divided  as  close  to 
its  insertion  as  the  incision  permits.  The  tendo  Achillis  is  split  laterally  with  a 
knife  about  one  and  one-half  inches  above  its  insertion.  A  long  pair  of  forceps 
is  passed  through  this  slit  in  the  tendo  Achillis,  going  from  within  outward,  and 
the  end  of  the  tendon  of  the  peroneus  longus  is  grasped  in  the  forceps  and 
pulled  through  this  slit  (Fig.  392).  According  to  the  method  of  Jones  the 
peroneus  longus  is  now  anchored  in  this   slit  with   two   sutures   of   chromic 


394 


OPERATIVE    SURGERY 


catgut,  which  transfix  the  teiulo  Achillis  and  the  tendon  of  the  peroneus 
long-US  as  it  passes  through  the  slit.  A  second  slit  is  made  in  the  lendo 
Achillis  lower  doAvn  and  just  above  its  insertion.  A  pair  of  forceps  is 
passed  through  this  slit  from  without  inward  and  the  end  of  the  peroneus 
longus  tendon  is  grasped  and  drawn  through  this  lower  slit  in  a  reversed  direction 
from  that  in  which  it  was  drawn  through  the  upper  slit  (Fig.  393).  The  tip 
of  the  tendon  which  has  been  grasped  with  forceps  is  cut  away  and  the  ten- 
don is  fastened  in  position  with  sutures  of  tanned  or  chromic  catgut.  The 
peroneus  longus  will  then  pull  upon  the  tendo  Achillis  and  so  will  correct 
the  talipes  calcaneus.  The  skin  is  closed  with  silkworm-gut  and  the  leg 
is  put  up  in  gauze  with  a  padded  posterior  flexible  splint,  which  is  curved 
well  down  over  the  sole  so  as  to  hold  the  foot  in  a  marked  equinus  posi- 
tion to  take  the  strain  from  the  transplanted  tendon. 


Fig.   393. — The  peroneus  tendon  is  drawn  through   the   second   slit   in   the  tendo  Achillis.      (Jones.) 

The  extensor  proprius  hallucis  may  be  transplanted  to  the  head  of  the 
first  metatarsal  bone  to  overcome  a  moderate  degree  of  claw  foot  due  to  a 
paralysis  of  the  short  flexors  of  the  foot.  Before  this  operation  is  done  the 
deformity  should  be  overcome  by  stretching  and  by  subcutaneous  tenotomy 
of  the  plantar  fascia,  and  also  by  excision  of  an  oval  portion  of  the  skin 
from  the  dorsdm  of  the  foot  in  front  of  the  ankle  (Fig.  394).  After  these 
preliminary  procedures  have  been  done  a  two-inch  incision  is  made  over  the 
tendon  of  the  extensor  proprius  hallucis,  beginning  at  the  level  of  the  web  be- 
tween the  great  and  the  second  toe  and  going  upward  (Fig.  395).  The 
tendon  with  its  sheath  is  isolated  and  mobilized  by  blunt  dissection  as  thor- 
oughly as  possible,  a  hemostat  is  applied  as   close   to   its  insertion  as  can 


THE  LOWER  EXTREMITY 


395 


Fig.   394.— Excision  of  a  diamond-shaped  area  of   skin  on  the  dorsum  of   the  foot.      (Sir  Robert  Jones.) 


Fig.    395. — Exposure   of  tendon   of   the   extensor   proprius   hallucis. 


be  done  after  extending  the  toe  and  the  tendon  is  divided.  About  one  and  one- 
half  inches  of  the  tendon  is  now  freed  from  the  surrounding  tissue  and  an  in- 
cision beneath  it  is  carried  down  to  the  periosteum,  which  is  divided  and  turned 


396 


OPERATIVE    SURGERY 


back,  exposing  the  bone  just  ])ehind  the  liead  of  the  first  metatarsal  bone.  A 
small  hole  is  drilled  throiiyli  the  first  metatarsal  just  l^ehind  its  head  and  this 
hole  is  enlarged  with  a  burr  until  it  is  such  a  size  that  the  tendon  can  be  carried 
through  the  opening  (Fig.  396).  A  half-inch  incision  is  made  through  the 
plantar  surface  of  the  foot  opposite  the  under  surface  of  the  head  of  the  first 
metatarsal  bone  and  is  carried  down  to  the  bone.  The  end  of  the  tendon  is 
transfixed  with  catgut  in  the  straight  needle  and  the  catgut  is  brought  through 
the  hole  in  the  metatarsal  bone  by  the  needle,  Avhich  is  passed  downward 
and  emerges  through  the  plantar  incision  (Fig.  397).  The  catgut  draws  the  ten- 
don through  the  hole  in  the  metatarsal  bone  and  the  tendon  is  fastened  in  this 
position  by  passing  one  end  of  the  catgut  through  a  part  of  the  plantar  fascia 


Fig.   396. — Drilling  a  liole  in  tlie  head  of  the  metatarsal  bone  for  transplantation   of  tendon   of  the  extensor 

proprius  hallucis.     (Sir  Robert  Jones. j 


and  tying  the  ends  of  the  catgut.  In  this  manner  the  end  of  the  tendon  is 
attached  to  the  plantar  fascia  and  is  prevented  from  slipping  back  through 
the  hole  in  the  metatarsal  bone.  The  incision  in  the  plantar  surface  of 
the  foot  is  closed  with  a  suture  of  silkworm-gut.  In  the  Avound  on  the 
dorsum  of  the  foot  the  tendon  and  periosteum  of  the  dorsum  of  the  meta- 
tarsal bone  are  united  by  a  suture  of  catgut  to  give  additional  fixation  and 
the  skin  is  closed  with  interrupted  silkworm-gut.  A  padded  splint  is  placed  along 
the  back  of  the  leg  and  the  sole  of  the  foot  to  keep  the  foot  at  a  right  angle. 
This  takes  the  s^train  from  the  transplanted  tendon  Avhile  it  is  healing  and  so 
gives  it  physiologic  rest.  The  stitches  are  removed  in  ten  days  and  massage  is 
instituted  in  about  three  Aveeks.  The  splint  is  removed  entirely  in  six  Aveeks 
and  the  patient  may  then  begin  to  Avalk. 

For  paralysis  of  muscles  about  the  knee  joint  transplantation  of  the  ham- 
string muscles,  inner  or  outer,  or  of  the  sartorius,  is  usually  done.    The  indica- 


THE    LOWER    EXTREMITY 


397 


tioiis  are  ijaralysis  or  paresis  of  tin;  ciuaelriceps  i'c'inoris.  If  all  of  the  muscle 
is  totally  paralyzed  it  avouIcI  probably  be  better  to  transplant  both  the  inner 
and  outer  hamstring  muscles,  or  at  least  the  biceps  and  the  semitendinosus 
and  graeilis.  The  mnscle  to  be  selected  also  depends  upon  the  extent  of 
the  paralysis  or  paresis.  The  muscle  to  be  transplanted  should  be  a  deep 
red  or  at  least  a  pinkish  red.  A  grey  muscle,  which  of  course  is  para- 
lyzed, will  be  of  no  service  if  transplanted.     If  the  outer  hamstring  muscle, 


Fig.    397. — The    method    of    drawing    a    tendon    through    a    drill    hole    in    the    head    of    the    metatarsal    bone. 

(Sir  Robert  Jones.) 


the  biceps,  is  used  it  should  be  inserted  into  the  inner  border  of  the  pa- 
tella to  stabilize  the  joint,  likewise  the  inner  hamstring  muscles  should  be 
placed  in  the  outer  portion  of  the  patella.  The  muscles  should  always  be  dis- 
sected up  one-half  their  length. 

According  to  Sir  Robert  Jones,  transplantation  of  the  biceps  tendon  is 
done  by  first  making  an  incision  about  five  inches  in  length  over  the  biceps, 
the  lower  portion  of  the  incision  reaching  not  quite  to  the  insertion  of  the 
tendon.  The  external  popliteal  nerve  lies  just  internal  to  the  biceps  tendon 
and  must  be  carefully  avoided.  After  the  tendon  is  dissected  down  nearly 
to  its  insertion  by  retracting  the  lower  angle  of  the  incision,  it  is  grasped 


398 


OPERATIVE   SURGERY 


with  a  pair  of  forceps  and  thoroughly  freed  with  knife  dissection.  It  is  care- 
fully cut,  bearing  in  mind  the  proximity  of  the  external  popliteal  nerve  (Fig. 
398),  and  is  turned  upward,  dissecting  the  under  surface,  and  the  muscle  and 
tendon  are  covered  with  gauze  Avrung  out  of  warm  salt  solution.  The  second 
incision,  about  three  inches  in  length,  extends  from  the  center  of  the  upper 
edge  of  the  patella  upward  and  outward  toward  the  upper  end  of  the  first 
wound.  A  tunnel  superficial  to  the  muscles  but  just  beneath  the  deep  fascia, 
is  made  from  this  wound  to  the  first.  This  tunnel  must  be  so  large  that  there 
is  no  possibility  of  the  muscle  being  caught  and  bound  by  it.    A  pair  of  large 


Fig.    398. Transplantation    of  tendon   of   the   biceps   femoris.      Exposure    of   the   tendon,    showing   proximity 

of  the  nerve.     (Sir  Robert  Jones.) 


forceps  is  passed  through  the  tunnel  from  the  second  incision  and  the  end  of  the 
biceps  tendon  is  grasped  and  drawn  through,  taking  care  not  to  twist  the  muscle 
in  this  procedure  (Fig.  399).  The  tendon  of  the  quadriceps  is  split  about 
half  an  inch  above  its  insertion  into  the  patella  and  the  tendon  of  the  biceps 
is  drawn  through  so  that  its  end  appears  on  the  surface  of  the  quadriceps 
tendon  (Fig.  400).  The  biceps  tendon  is  here  united  to  the  quadriceps  ten- 
don by  three  sutures  of  tanned  or  chromic  catgut.  The  aponeurosis  be- 
low the  tunnel  is  split  downward  as  far  as  the  upper  edge  of  the  patella  and 
the  end  of  the  biceps  tendon  is  sutured  into  this  field  with  tanned  or  chromic 


THE    LOWER    EXTREMITY 


399 


patg-ut.     The  skin  Avoniid  is  closed  in  the  usual  manner.     Splints  are  applied 
to  yive  the  leg  and  thigh  eomi)lele  rest  during  healing. 

Usually  where  the  inner  hamstring  muscles  are  vigorous  and  it  is  not 
necessary  to  transplant  tendons  from  botli  the  inner  and  the  outer  side,  the  semi- 
tendinosus  and  gracilis  are  transplanted  in  preference  to  the  biceps.  An  in- 
cision is  begun  about  one  inch  above  and  a  half  inch  posterior  to  the  inner 
condyle  of  the  femur  and  is  carried  through  the  skin  and  subcutaneous  tissue 
parallel  to  the  femur  to  about  the  junction  of  the  middle  and  upper  third  of 
the  thigh.  The  muscles  are  examined  to  see  that  they  are  in  good  condition. 
The  bellv  of  the  semimembranosus  first  comes  into  view,  then  its  tendon,  and 


Fig.    399. — A   tunnel   has  been    made   and   the  biceps  tendon  is  to   be   drawn   through   to   the   second   incision. 

(Jones.) 

underneath  this  is  seen  the  semitendinosus  and  the  gracilis,  both  of  which  have 
long  thin  tendons  and  are  more  suitable  for  transplantation  than  the  semi- 
membranosus. The  skin  at  the  loAver  angle  of  the  wound  is  retracted  in  order 
not  to  carry  the  incision  far  enough  down  to  weaken  the  structures  around  the 
knee  joint.  The  semitendinosus  and  the  gracilis  are  dissected  out  and  their 
tendons  clamped  and  divided  as  near  their  insertion  as  possible,  while  retract- 
ing the  lower  angle  of  the  wound.  The  tendons  and  muscles  are  dissected 
freely  to  near  the  upper  angle  of  the  wound.  A  second  incision  is  made  on 
the  anterior  portion  of  the  thigh  about  its  middle  and  down  to  the  quadriceps 
muscle.    A  tunnel  is  made  from  this  incision  backward,  connecting  with  the  upper 


400 


Ol'KRATIVE    SURGERY 


portion  of  the  tirrst  incision.  Tlic  ends  of  the  tendons  of  the  semitendinosus 
and  gracilis  are  drawn  through  and  quilted  with  braided  silk. 

The  mnsele  and  tendon  are  always  protected  with  gauze  wrung  out  of  moist 
salt  solution  wliile  the  other  incisions  are  being  made. 

A  third  incision  begins  about  one  inch  below  the  upper  edge  of  the  pa- 
tella and  is  carried  upward  in  the  midline  about  two  and  one-half  inches  and 
goes  through  the  superficial  fascia  and  fat.  A  long  probe,  or  a  pair  of  forceps, 
or  a  tendon  carrier  is  inserted  into  this  last  incision  and  makes  a  broad  tunnel 
between  it  and  the  second  incision.  The  silk  having  been  quilted  in  the  tendons 
of  the  semitendinosus  and  the  gracilis,  they  are  pulled  down  into  the  third  in- 


Fig.    400. — The   tendon   of   the    quadriceps    has    been   split   and   the    tendon    of    the    biceps   is   drawn    through. 

(Jones.) 


cision  and  the  ends  of  the  silk  are  threaded  into  a  needle  and  sutured  to 
the  quadriceps  tendon  just  above  the  patella.  The  muscle  tissue  itself  is 
also  attached  to  the  quadriceps  muscle  and  tendon  just  above  the  patella 
after  slightly  scarifying  the  quadriceps.  These  sutures  may  be  chromic  or 
tanned  catgut  or  silk.  The  ends  of  the  silk  sutures  from  the  transplanted  ten- 
dons are  again  threaded  into  needles  after  the  silk  has  been  tied  just  above 
the  patella  and  are  carried  beneath  the  skin  to  a  fourth  small  curved  incision 
over  the  external  portion  of  the  head  of  the  tibia.  Here  the  silk  sutures  are 
quilted  into  the  periosteum,  tied  three  times,  and  the  knot  is  pressed  doAvn 


TTIE   LOWER   EXTREMITY  401 

Hal.     Till'  ileeprv  st  nii'l  iirrs  arr   lii'oiiglil    I  o^rl  lici-   by   cliroiiiii-   ov  tanned  cat- 
tiiit  aiul  the  skin  is  elosed  in  the  usual  nianner  with  silkwonn-gut  or  silk. 

Oeea.sionally  it  may  be  necessary  to  transplant  both  the  inner  and  the 
outer  hamstring'  muscles  into  the  tendon  of  the  quadriceps.  Here  it  may  be 
best  to  quilt  the  end  of  the  biceps  with  silk,  suture  it  into  the  quadriceps 
tendon,  carry  the  silk  doAvn  to  the  head  of  the  tibia  on  the  inner  side,  and 
qnilt  it  into  the  periosteum.  In  the  technic  of  Sir  Robert  Jones,  however,  he 
relies  upon  splitting  the  tendon  of  the  quadriceps,  drawing  the  biceps  tendon 
through,  and  fastening  it  lower  doAvn  with  tanned  or  chromic  catgut.  Either 
of  these  methods  is  excellent,  but  the  braided  silk,  if  the  knots  are  tied  to  lie 
flat,  Avill  probably  afford  a  firmer  insertion  where  on  account  of  the  paralysis 
it  appears  that  the  union  may  not  be  strong. 

If  the  sartorius  muscle  is  to  be  transplanted  its  insertion  is  exposed  and 
the  muscle  divided  near  its  insertion,  quilted  with  silk  at  its  lower  end,  and 
brought  through  an  incision  in  the  middle  anterior  surface  of  the  thigh,  as  in 
transplantation  of  the  semitendinosus  and  gracilis.  The  end  of  the  muscle 
with  the  silk  quilted  in  is  brought  through  a  wide  subcutaneous  tunnel  from 
an  incision  just  above  the  patella  to  the  second  incision  and  is  sutured  by  the 
silk  in  the  usual  manner  into  the  tendon  of  the  quadriceps  just  above  the 
patella.  The  silk  can  also  be  carried  down  and  quilted  into  the  periosteum 
in  the  midline  of  the  tibia  just  below  the  patella.  The  quadriceps  muscle  and 
the  sartorius  are  scarified  and  sutured  together. 

After  all  tendon  transplantations  the  leg  should  be  placed  in  such  a 
position  that  there  will  be  the  least  possible  strain  upon  the  tendon.  Slight 
passive  motion  is  begun  after  three  weeks,  but  no  active  strain  should  be  put 
upon  the  tendon  for  three  or  four  weeks  longer. 

DEFORMITIES  OF  THE  ANKLE  JOINT 

Before  a  tendon  transplantation  is  done  any  defect  in  the  joint  over 
which  the  tendon  acts  must  be  corrected  so  far  as  possible.  In  club  foot  the 
foot  must  be  brought  to  its  normal  or  to  an  overcorrected  position.  Club 
foot  may  usually  be  straightened  in  a  newborn  infant  by  manual  manipula- 
tion and  holding  the  foot  in  position  with  adhesive  plaster  and  straps.  In 
older  children  a  Thomas  foot  wrench  or  a  Bradford  wrench  is  used.  The 
patient  lies  on  the  abdomen  with  the  leg  flexed  and  in  this  position  the  maxi- 
mum amount  of  force  can  be  most  conveniently  brought  to  bear. 

A  common  form  of  congenital  club  foot  is  an  equinovarus,  in  which  the 
heel  is  drawn  up  and  the  sole  of  the  foot  is  turned  in.  In  pronounced  cases 
the  patient  w^alks  upon  the  dorsum  of  the  foot.  Formerly,  for  this  type  of 
club  foot,  the  Phelps  operation  was  much  in  vogue.  This  operation  consisted 
in  cutting  all  of  the  resisting  structures  on  the  inner  side  of  the  plantar  sur- 
face of  the  foot.  The  original  operation  left  a  large  deep  raw  surface  which 
filled  with  granulation  tissue  and  formed  a  large  scar.  An  improvement  w^as 
introduced  in  Avhich  a  Y-shaped  incision  was  made  into  the  skin  with  its  base 


402 


OPERATIVE    SURGERY 


about  the  middle  of  the  sole  of  the  foot  and  the  apex  in  front  of  and  below  the 
internal  malleolus.  Subsequent  manijpulations,  however,  are  likely  to  open 
the  wound. 

The  preferable  procedure  is  first  to  correct  the  foot  as  far  as  possible  by 
manual  manipulations  or  the  foot  wrench.  When  the  equinovarus  is  extreme 
it  may  be  necessary  to  remove  a  small  wedge  of  bone  from  the  anterior 
end  of  the  os  calcis  and  the  astragalus.  This  is  not  necessary  in  the 
paralytic  type  of  club  foot.  After  manipulating  the  foot  tenotomy  of  the 
tendo  Achillis  is  done  and  then  a  subcutaneous  tenotomy  of  the  plantar  fascia. 
If  after  this  procedure  an  overcorrection  is  not  obtained  a  small  wedge  of 
bone  is  removed  from  the  os  calcis  and  the  astragalus  through  an  incision  just 
in  front  of  the  external  malleolus  and  extending  tow^ard  the  base  of  the  fifth 
metatarsal  bone.  This  incision  is  carried  down  to  the  bone,  the  tendons  are 
retracted,  and  the  prominent  part  of  the  astragalus  is  exposed.  A  small  wedge 
of  bone  is  removed  from  the  astragalus  with  an  osteotome,  which  should  enter 


Fig.  401. — Correction  of  club  foot  by  excision 
of  bone  from  the  os  calcis  and  the  astragalus. 
The  bone  to  be  excised  is  represented  by  the 
shaded  area. 


Fig. 


402. — lyine    of    incision    for    the    operation    of 
Ober  for  correction  of  club  foot. 


the  bone  at  some  distance  from  the  tibia  so  as  not  to  interfere  with  the  ankle 
joint.  If  this  proves  insufficient  a  small  amount  of  bone  is  removed  from  the 
front  end  of  the  os  calcis  (Fig.  401). 

When  the  os  calcis  is  markedly  tilted  the  operation  of  Ober  is  indicated. 
Here  the  foot  is  manipulated  and  stretched  as  far  as  possible  and  an  incision 
is  made  on  the  inner  side  of  the  tibia  from  two  inches  above  the  internal 
malleolus,  curving  slightly  downward  and  forward  to  the  scaphoid  (Fig.  402). 
The  incision  is  carried  to  the  bone  and  the  periosteum  over  the  inner  malleolus 
is  exposed  and  incised  transversely  about  one  inch  above  the  tip  of  the 
malleolus  while  the  skin  incision  is  strongly  retracted.     The  periosteum  is 


THE   LOWER   EXTREMITY 


403 


also  incised  on  each  side  of  the  malleolus  so  it  can  be  raised  from  the  bone. 
The  lower  and  front  portions  of  the  periosteum  remain  attached  to  the  liga- 
ments of  the  ankle  joint.  The  periosteum  and  the  ligaments  are  separated 
from  the  bone  with  an  osteotome  and  this  separation  is  carried  to  the  ligaments 
of  the  astragalus  and  os  calcis  and  the  astragalus  and  scaphoid  until  the  foot 
can  swing  outward  freely  (Figs.  403  and  404).  After  loosening  the  upper  end 
of  these  ligaments  the  foot  is  manipulated.  The  tendo  Achillis  is  cut  last  of 
all  and  the  foot  is  then  again  manipulated,  if  necessary  with  a  wrench,  in 
order  to  place  it  in  an  overcorrect  position.    The  periosteum  is  not  sutured  but 


Fig.  403. — Mobilization  of  the  periosteum  and  ligaments  in  the  operation  of  Ober. 

the  deeper  structures  are  brought  together  with  tanned  or  chromic  catgut  and 
the  skin  is  sutured  as  usual  with  silk  or  silkworm-gut.  A  plaster  of  Paris 
bandage  is  applied  over  the  dressing.  A  liberal  amount  of  wadding  is  used 
when  the  plaster  is  applied  and  care  is  taken  to  prevent  squeezing  together  the 
toes.  It  is  probably  best  to  apply  plaster  over  the  foot  and  over  the  leg  sep- 
arately and  after  these  casts  have  slightly  hardened  to  secure  the  proper 
position  and  then  apply  plaster  to  connect  these  two  segments  of  the  cast. 
The  equinovalgus  or  the  calcaneovalgus  type  of  club  foot  is  usually  due 
to  paralysis,  while  the  equinovarus  type  is  almost  always  congenital.  In  the 
valgus  club  foot  the  balance  of  the  foot  should  be  restored  by  overcorrecting 


404 


OPERATIVE    SURGERY 


the  deformity  and  then  transplanting  tendons,  as  lias  been  described.  When 
there  is  marked  lack  of  stability  at  the  ankle  joint  the  astragalus  may  be 
excised  with  displacement  of  the  foot  backward.  When  the  extensors  of  the 
toes  are  very  active  and  "hammer"  toes  result,  it  may  be  well  to  transplant 
a  tendon  of  the  great  toe  into  the  head  of  the  metatarsal  bone  and  attach 
the  other  extensors  to  the  tarsus  after  dividing  them  below.  In  extreme 
valgus,  whether  ealcaneo  or  equinovalgus,  Avith  a  flail  joint,  astragalectomy 
is  a  satisfactory  procedure.  The  correction  of  the  valgus  may,  however,  be 
possible  with  the  use  of  wrenches  and  the  transplantation  of  tendons.     When 


Fig.   404. — Mobilization   of  anterior  portion   of  periosteum  and   ligaments  in   the  operation  of  Ober. 

the  bone  is  greatly  deformed  a  wedge  may  be  removed  from  the  scaphoid  or 
from  the  astragalus,  followed  by  transplantation  of  tendons.  Both  tibial 
tendons  may  be  buried  into  grooves  in  the  tibia  anteriorly  and  posteriorly,  to 
act  as  internal  ligaments  for  the  joint. 

In  removing,  a  wedge  of  bone  from  the  scaphoid  an  incision  is  made  one- 
half  inch  in  front  of,  and  the  same  distance  below  the  internal  malleolus  and 
extends  forward  to  the  first  metatarsal  bone.  The  incision  is  carried  to 
the  bone  and  the  tissues  are  dissected  up  and  retracted  in  one  layer.  The 
tendons  of  the  tibial  muscles  are  carefully  retracted.  A  wedge  of  bone  is 
removed  from  the  scaphoid  and  adjoining  bone.     The  wedge  is  sufficiently 


THE   LOWER   EXTREMITY  405 

large  to  allow  the  foot  to  come  in  satisfactory  position.    The  tissues  are  closed 
ill  the  usual  way. 

Pure  talipes  calcaneus  is  usually  due  to  paralysis  of  the  muscles  supplying 
the  tendo  Achillis  and  is  corrected  by  first  straightening  the  foot  and  then 
transplanting  the  tendons  of  the  peroneus  muscles  into  the  tendo  Achillis, 
or  if  the  peroneus  muscles  are  affected  the  posterior  tibial  or  the  flexors  of 
the  toes  can  be  used.  The  operation  in  which  this  is  done  and  an  area  of 
skin  removed  from  the  anterior  part  of  the  ankle  has  been  described. 

In  "hammer"  toe  or  ''claw  foot"  tenotomy  of  the  contracting  tendons 
and  stretching  of  the  toes  is  usually  sufficient.  If  it  is  not,  however,  and  es- 
pecially if  the  case  is  of  long  standing,  a  small  piece  of  bone  is  removed  and 
then  tenotomy  is  done.  If  bone  is  to  be  excised  an  incision  is  made  three- 
fourths  of  an  inch  long  to  the  inner  or  outer  side  of  the  dorsal  tendon  down  to 
the  bone.  The  periosteum  is  divided  and  raised  and  the  joint  excised  sub- 
periosteally  by  dividing  the  distal  end  of  the  proximal  phalanx  and  the  prox- 
imal end  of  the  second  phalanx.  Sufficient  bone  should  be  excised  to  permit 
free  extension  and  flexion  of  the  joint.  The  deeper  tissues  are  sutured  with 
fine  tanned  or  chromic  catgut  and  the  skin  is  closed  in  the  usual  way.  A 
well  padded  splint  is  applied  to  the  whole  foot  and  toes  and  a  plaster  of  Paris 
bandage  over  this.  The  patient  can  walk  with  the  plaster  cast  in  about  two 
Aveeks  and  the  toes  may  be  given  freedom  in  two  weeks  longer.  A  broad 
shoe  should  be  used. 

In  marked  hallux  valgus,  particularly  where  there  is  callus  formation,  the 
deformity  can  be  corrected  by  a  curved  incision  including  the  callus  and  with 
the  base  below.  This  is  dissected  up,  according  to  the  method  of  C.  H.  Mayo, 
and  a  second  flap  is  made  of  the  ligaments  and  the  bursa  with  its  base  just 
back  of  the  head  of  the  metatarsal  bone.  As  much  of  the  head  of  the  meta- 
tarsal bone  is  excised  as  seems  necessary  to  bring  the  toe  in  the  proper  posi- 
tion, taking  the  bone  only  from  the  inner  side  of  the  head.  The  flap  consist- 
ing of  ligament  and  bursa  is  carried  over  the  raw  surface  left  by  excising  the 
head  of  the  metatarsal  bone  and  is  fastened  in  position  by  one  or  two  sutures  of 
tanned  or  chromic  catgut.  The  U-shaped  skin  flap  is  sutured  and  the  toe  is 
kept  in  a  splint  for  about  four  weeks.  After  that  some  padding  is  placed  be- 
tween the  great  toe  and  the  next  toe  for  several  months  and  broad  shoes 
should  be  used. 

When  the  deformity  is  not  extreme  tenotomy  of  the  extensor  of  the  great 
toe  sometimes  affords  relief  when  accompanied  by  osteotomy  through  the 
base  of  the  head  of  the  metatarsal  bone.  For  this  operation  a  longitudinal 
incision  one  inch  long  is  made  on  the  inner  side  of  the  tendon  of  the  great 
toe  and  over  the  head  of  the  metatarsal  bone.  Osteotomy  is  done  through 
the  head  of  the  bone  and  the  deformity  overcorrected.  A  wooden  plantar 
splint  is  applied. 

All  of  the  head  of  the  metatarsal  bone  should  never  be  removed  as  this 
does  away  with  the  weight  bearing  part  of  this  bone,  which  is  very  important. 
Exostoses  may  be  trimmed  or  a  small  wedge-shaped  part  of  the  bone  removed. 


406 


OPERATIVE    SURGERY 


If  more  than  this  is  necessary  instead  of  removing  the  whole  of  the  head 
an  osteotomy  should  be  done.  It  will  require  considerable  time  for  the 
bone  to  unite  firmly  but  this  operation  gives  much  better  eventual  results  than 

can  be  obtained  by  removing  the  head  of  the  bone,  which  has  a  very  important 
function. 


INGROWING  NAIL 

An  ingrowing  toe  nail  that  cannot  be  cured  by  proper  care  of  the  nail  is 
relieved  by  an  operation  that  removes  about  one-fourth  of  the  nail  and  the 
adjoining  soft  tissues.  This  can  be  done  under  a  local  anesthetic  either  by 
infiltrating  the  base  of  the  toe  and  blocking  the  nerves  or  by  directly  injecting 
the  tissues  that  are  to  be  the  site  of  the  operation.  The  incision  begins  in  the 
soft  tissues  about  on  the  level  with  the  tip  of  the  nail  and  is  carried  back 
deeply  to  a  point  about  half  way  betAveen  the  base  of  the  nail  and  the' next 
joint.  Another  incision  parallel  with  this  and  removing  about  one-fourth  of 
the  toe  nail  is  begun  by  inserting  the  point  of  the  knife  under  the  nail  with 
the  cutting  edge  upward  and  splitting  the  nail  from  below  upward  from  its 
tip  through  its  base.     The  incision  is  then  inclined  so  as  to  meet  the  first  in- 


Fig.  40S. — Lines  of  incision  for  operation  for  ingrowing  toe  nail. 

cision  at  an  angle  (Fig.  405).  The  mass  of  tissue  included  by  these  two  in- 
cisions is  excised  in  one  piece,  including  the  soft  tissues,  about  one-fourth  of  the 
nail  and  the  matrix  of  the  nail.  It  is  quite  important  to  remove  the  tissue  cells 
that  constitute  the  matrix  of  the  removed  portion  of  the  nail  so  that  here  the  ex- 
cision of  the  tissue  is  carried  down  to  the  periosteum,  as  otherwise  a  few  cells 
that  are  left  will  produce  fragments  of  nail  that  will  be  ^^ainful  and  difficult  to 
remove.  The  wound  is  sutured  with  interrupted  chromic  or  tanned  catgut  in 
a  sharp  needle,  the  first  suture  being  introduced  at  the  inner  angle  of  the  Avound 
and  tied  sufficiently  tightly  to  control  the  bleeding.  Two  or  three  other 
sutures  are  inserted  from  the  skin  flap,  bringing  the  needle  through  the  nail 
from  below  upward.     In  this  manner  the  nail  can  be  easily  penetrated.     The 


THE   LOWER    EXTREMITY 


407 


tourniquet  is  removed  and  if  any  spurting  point  is  left  an  additional  suture 
is  placed. 

THE  JOINTS 

In  marked  paralysis  about  the  ankle  when  there  is  complete  flail  foot,  or 
when  the  talipes  cannot  be  otherwise  corrected,  the  astragalus  may  be  excised. 
This  is  done  through  an  incision  beginning  back  of  the  external  malleolus 
and  one  inch  above  it.    The  incision  is  carried  down  posteriorly  to  the  external 
malleolus,  around  its  lower  extremity  to  the  middle  of  the  anterior  portion  of 
the  tarsus,  and  then  directly  down  to  the  base  of  the  second  metatarsal  bone. 
Another  incision  that   may   be   used  is   a   vertical   incision   anterior   to   the 
external  malleolus.     It  begins  just  anterior  to  the  fibula  and  about  one  and 
one-half  inches  above  the  tip  of  the  external  malleolus  and  is  carried  down 
along  the  inner  side  of  the  peroneus  tendon.    The  latter  incision  is  preferable 
when  the  operation  is  for  marked  paralysis  where  there  is  an  effort  to  stabilize 
the  joint,  as  this  incision  interferes  but  little  with  the  circulation.     The  liga- 
ments from  the  external  malleolus  are  separated  with  an  osteotome  subperi- 
osteally  and  strong  retraction  is  made  on  the  two  margins  of  the  incision. 
The  ligaments  over  the  os  calcis  and  those  binding  the  astragalus  are  also 
separated  subperiosteally.     The  anterior  portion  of  the  incision  is  strongly 
retracted  and  the  tissues  are  lifted  from  the  astragalus  and  the  neck  of  the 
astragalus  is  divided  as  far  forward  as  possible.     An  osteotome  is  inserted 
above  the  astragalus,  between  it  and  the  tibia,  and  while  the  foot  is  adducted 
the  astragalus  is  cut  down  upon  vertically  leaving  a  flat  portion  of  the  as- 
tragalus next  to  the  internal  malleolus.    The  body  of  the  astragalus  is  in  this 
manner  easily  removed  as  the  foot  is  dislocated  inward  and  the  small  portion 
that  has  been  left  attached  to  the  internal  malleolus  can  be  removed  with  the 
osteotome  and  forceps.    After  the  removal  of  the  astragalus  the  foot  is  dis- 
placed inward  to  expose  both  malleoli  and  any  tissue  that  prevents  the  back- 
ward displacement  of  the  foot  is  removed  or  corrected.     The  foot  is  then 
displaced  backward. 

In  a  flail  joint  silk  may  often  be  inserted  and  the  joint  thus  held  moder- 
ately stiff.  This  may  be  done  by  an  open  or  a  subcutaneous  method.  Silk  liga- 
ments are  particularly  useful  at  the  ankle  to  prevent  toe  dropping,  which  is  a 
result  of  paralysis,  and  they  also  increase  the  lateral  stability  of  the  joint. 
The  silk  ligaments  may  be  placed  in  an  open  operation.  Here  the  incision 
is  made  over  the  anterior  part  of  the  lower  third  of  the  tibia,  cutting  down 
to  the  periosteum,  which  is  incised  and  stripped  up.  The  silk  is  quilted  in  the 
tw^o  edges  of  the  periosteum  and  a  second  piece  of  silk  is  tied  to  the  two  ends 
that  have  been  quilted.  This  gives  four  strands.  A  curved  incision  is  made 
over  that  part  of  the  foot  in  which  the  silk  is  to  be  inserted  and  the  silk  is 
carried  subcutaneously  to  this  incision.  It  is  then  quilted  in  and  tied,  two 
strands  being  used  on  the  inner  side  and  two  on  the  outer  side  of  the  foot. 
Usually  the  inner  incision  is  made  over  the  scaphoid  and  internal  cuneiform 


408 


OPERATIVE    SURGERY 


bones  and  the  onter  over  the  cnljoid.    The  ligaments,  as  Avell  as  the  periostenm, 
are  eanght  in  the  qnilting  sutnre. 

Bradford  nses  the  snbcutaneons  method  and  begins  at  a  point  on  the 
lower  third  of  the  tibia.  The  skin  over  the  bone  is  retracted  so  as  not  to  be 
in  its  normal  position  and  a  drill  with  an  eye  at  the  point  is  passed  through 
the  skin  and  the  tibia.  As  it  emerges  from  the  bone  the  skin  is  pulled  for- 
ward before  the  drill  perforates  it  (Figs.  406  and  407).  This  procedure  pre- 
vents the  opening  in  the  bone  being  opposite  the  puncture  in  the  skin.  The 
two  ends  of  a  silkAvorm-gut  strand  are  passed  through  the  eye  of  the  drill  and 
the  drill  is  withdrawn.    Braided  silk  is  caught  in  the  loop  of  the  silkworm-gut 


Fig.  406. — Insertion  of  braided  silk  for  correc- 
tion of  flail  ankle  joint.  The  diagram  shows  the 
position  of  the  drill  holes  in  the  bone.  (Method 
of  Bradford.) 


Fig.   407.- 


-The   drill    has   entered   the   tibia. 
(Bradford.) 


suture  and  drawn  through.  In  a  similar  way  the  tarsal  bones  are  drilled  from 
within  outward,  pulling  the  skin  to  one  side,  and  drawing  through  a  doubled 
strand  of  silkworm-gut  (Fig.  408).  The  silk  used  is  very  heavy  braided  silk, 
which  is  first  carried  through  the  hole  in  the  tibia.  The  outer  end  of  the  silk 
is  then  passed  subcutaneously  to  the  loop  of  silkworm-gut  through  the  tarsus 
and  is  thus  drawn  through  the  tarsus  (Figs.  409  and  410).  Then  by  a  carrier 
the  end  of  the  silk  that  comes  through  the  inner  hole  of  the  tarsus  is  carried 
subcutaneously  to  the  end  of  silk  that  has  been  left  at  the  inner  hole  in  the 
tibia  (Fig.  411).  The  silk  is  tied  firmly  in  three  knots,  the  ends  are  cut,  and  the 
skin  is  drawn  over  the  knots  (Fig.  412).  Strips  of  fascia  lata  are  sometimes 
used  instead  of  silk  ligatures. 


THE   LOWER   EXTREMITY 


409 


Fig.  408. — :The  drill  hole  in  the  tibia  has  been 
made  and  the  silk  is  being  pulled  through. 
(Bradford.) 


Fig.  409. — A  tunnel  has  been  made  on  the 
outer  side  of  the  foot,  and  the  silk  is  being  pulled 
through   the   tunnel.      (Bradford.) 


Fi£ 


410. — The    loop    is   being   pulled    through    the 
drill    hole    in    the    tarsus.       (Bradford.) 


Fig.  411. — A  tunnel  has  been  made  on  the 
inner  side  of  the  foot  and  the  second  end  of 
the   silk   is  being   pulled   through   to    the    first    end. 


410 


OPERATIVE   SURGERY 


Excision  of  the  ankle  joint  is  not  often  necessary,  but  may  be  done 
through  a  transverse  curved  external  incision  which  begins  on  the  dorsum 
of  the  foot  midway  between  the  ankle  joint  and  the  articulation  of  the  astrag- 
alus and  scaphoid.  The  incision  is  carried  backward  horizontally  below  and 
beyond  the  external  malleolus,  and  then  up  between  the  tendo  Achillis  and 
the  tendons  of  the  peroneus  muscles  to  a  point  about  three  inches  above  the 
joint  (Fig.  413).  The  superficial  peroneal  nerve  should  be  identified  and 
retracted  out  of  the  way.  The  extensor  tendons  and  the  tendons  of  the  pero- 
neus muscles  are  retracted  inward  and  the  sural  nerve  and  the  small  saphenous 
vein  are  protected  behind.  The  incision  is  carried  down  to  the  fibula  and  the 
astragalus  and  divides  the  capsule  of  the  ankle  joint  back  to  the  external 


Fig.  412. — The  knots  have  been  tied.     The  position  of  the  silk  in  the   skeleton  of  the  foot  and  leg  is  shown 

in   the   diagram. 


malleolus.  The  bands  of  the  external  lateral  ligaments  -are  separated  from 
the  external  malleolus.  The  sheath  of  the  peroneus  tendons  is  incised  pos- 
teriorly to  the  fibula.  The  tendons  are  removed  from  the  sheath  and  retracted 
backward  by  splitting  the  sheath  of  the  tendons  high  up.  It  will  be  unneces- 
sary to  divide  the  tendons  if  they  can  be  retracted.  Sometimes,  however, 
they  must  be  divided.  The  periosteum  is  incised  over  the  fibula  and  separated 
along  with  the  adherent  peroneus  sheath  from  the  posterior  surface  of  the 
fibula  and  tibia.  The  periosteum  is  separated  from  the  anterior  surface  of  the 
fibula  and  tibia,  which  also  removes  the  attachment  of  the  capsule  of  the  joint 
in  this  region  where  it  is  adherent  to  the  periosteum.  The  foot  is  bent  forci- 
bly inward  until  it  is  completely  displaced  and  the  inner  side  of  the  foot  rests 
against  the  leg  turning  on  the  internal  lateral  ligament  as  a  hinge.  As  much 
of  the  bone  is  removed  as  is  necessary.  It  is  particularly  desirable  to  saw  off 
no  more  bone  from  the  astragalus  than  may  be  necessary  and  small  separate 


THE    LOWER   EXTREMITY 


411 


foci  should  be  chiseled  out  and  not  curetted.  In  this  manner  healthy  bone 
around  the  focus  is  cut  with  a  chisel  and  the  focus  is  thus  removed,  whereas 
the  curet  often  forces  diseased  tissue  further  into  healthy  bone.  After  a 
sufficient  amount  of  bone  has  been  removed  the  peroneus  tendons  are  sutured, 
if  it  has  been  necessary  to  divide  them,  or  simply  replaced  in  their  sheaths,  if  they 
have  been  preserved. 

Excision  of  the  astragalus  for  disease  of  the  bone  or  joint  may  be  done 
by  an  external  curved  incision,  or  by  an  external  angular  and  internal  curved 
incision.  The  external  curved  incision  begins  about  three  inches  above  the 
ankle  at  the  anterior  border  of  the  fibula  and  is  carried  down  external  to  the 
peroneus  tertius  tendon  and  superficial  peroneal  nerve  and  then  curves  for- 
ward over  the  outer  portion  of  the  astragalus  to  the  base  of  the  fifth  meta- 
tarsal bone.  The  peroneus  tendon  is  retracted  inward  and  the  extensor  brevis 
digitorum  is  retracted  outAvard.  In  the  space  thus  exposed  the  capsule  of  the 
ankle  joint  is  incised  and  the  neck  of  the  astragalus  and  the  lower  ends  of  the 


Fig.    413. — L,ines    of   incision    for:    A,    excision    of    ankle    joint    (method    of    Lauenstein) ;    B,    excision    of    os 
calcis   (Oilier);   C,  excision  of  astragalus   (Oilier). 


tibia  and  fibula  are  freed.  The  calcaneo-astragaloid  ligament  and  the  anterior 
and  posterior  bands  of  the  external  lateral  ligament  are  divided.  The  attach- 
ment between  the  astragalus  and  os  calcis  and  scaphoid  are  cut  with  a  stout 
knife  and  the  foot  is  inverted  forcibly  and  the  inner  surface  of  the  astragalus 
is  freed  as  much  as  possible,  taking  care  to  avoid  injury  to  the  posterior  tibial 
vessels  and  nerves.  The  astragalus  is  removed  with  bone  forceps,  any  further 
attachments  being  divided  with  scissors.  The  ends  of  the  ligaments  should  be 
brought  together  with  chromic  or  tanned  catgut  and  the  skin  closed  in  the 
usual  manner. 

In  intractable  club  foot,  particularly  the  type  that  has  recurred  after 
operation,  the  bony  structures  of  the  foot  are  often  so  deformed  that  even 
correction  of  the  soft  parts  does  not  give  the  desired  results.  Here  the  method 
of  bone  grafting  emploj^ed  by  Albee  may  be  utilized.  In  order  to  see  the 
structures  satisfactorily  it  is  necessary  to  use  an  Esmarch  and  a  tourniquet. 


412 


OPERATIVE    SURGERY 


The  teudo  Acliillis  is  divided  in  the  usual  manner,  the  contracted  plantar 
fascia  is  cut  subcutaneously,  and  the  foot  is  forced  into  as  good  position  as  can 
be  attained.  In  the  type  of  club  foot  in  "which  bone  grafting  is  indicated 
methods  such  as  this  with  the  use  of  manual  force  and  the  foot  wrench  have 
already  resulted  in  recurrence,  so  bone  grafting  must  be  done  and  a  U-shaped 
incision  is  made  on  the  inner  and  upper  portion  of  the  foot  with  the  base  of 
the  flap  i^osteriorly.  The  upper  line  of  the  flap  begins  in  front  of  the  middle  of 
the  ankle  joint  and  the  incision  is  carried  forward  on  the  dorsum  of  the 
foot  almost  to  the  tarsometatarsal  joint  where  it  curves  downward  and  in- 
ward across  the  base  of  the  first  metatarsal  bone  and  then  is  carried  back  to 
a  point  just  below  and  in  front  of  the  internal  malleolus.  This  flap,  in- 
cluding subcutaneous  tissue,  is  turned  back  and  exposes  the  scaphoid  bone. 
The  bone  is  split  with  a  thin  osteotome  into  two  halves  (Fig.  414).  The 
foot  is  then  forced  into  overcorrection,  which  widens  the  gap  in  the  scap- 
hoid   (Fig.   415).     Any   soft   tissues   that   are   markedly  resisting   the   over- 


Fig.  414. — Incision  for  bone  grafting  in  intractable 
club   foot. 


41 S. — Club    foot    has    been    straightened    and 
is   ready  to   receive  the  bone  graft. 


correction  of  the  foot  are  divided.  The  gap  in  the  bone  is  measured  with 
calipers  and  after  exposing  the  inner  surface  of  the  tibia,  by  an  incision  in 
the  skin  and  turning  back  the  periosteum,  a  wedge  of  bone  is  cut  from  the 
internal  surface  and  the  crest  of  the  tibia  by  a  motor  saw.  A  thin  osteotome 
can  be  used  for  this  but  a  motor  saw  is  preferable.  The  base  of  the  wedge 
is  at  the  crest  of  the  tibia  and  the  apex  is  directed  inward  and  toward  the 
medullary  cavity.  A  hole  is  drilled  in  the  base  of  the  wedge  before  it  is  re- 
moved so  that  it  can  be  fixed  in  its  new  position  with  a  suture.  It  is  easier 
to  drill  the  hole  before  the  wedge  is  entirely  free.  The  wedge  of  bone  is  im- 
mediately transferred  to  the  gap  in  the  scaphoid  and  should  fit  so  snugly 
that  it  prevents  the  recurrence  of  bony  deformity.  The  edges  of  the  scaphoid 
are  drilled  and  kangaroo  tendon  is  passed  through  the  hole  in  the  scaphoid 
and  the  hole  in  the  graft  and  tied  so  as  to  hold  the  graft  in  position.  A  bone  peg 
may  be  utilized  for  this  purpose.  When  the  graft  has  been  inserted  and  fixed 
the  foot  shoukl  remain  in  this  overcorrectcd  position  after  it  has  been  released. 


THE   LOWER   EXTREMITY  413 

I'sually  the  overcoriH^-rKiii  iiiakcs  i1  impossible  for  tlio  Ha])  to  l)e  sutured  to  cover 
the  \vhoU^  Avouiul,  but  it  will  at  least  cover  the  grafted  bone  and  the  rest  of  the 
wound  must  be  left  to  heal  by  oi-anulations,  or  to  be  closed  by  a  plastic  procedure 
later  on.  A  few  layers  of  smooth  gauze  are  placed  between  the  toes,  the  foot  is 
dressed,  and  plaster  of  Paris  applied  over  the  foot  to  hold  it  in  the  over- 
corrected  position,  the  knee  being  flexed  to  almost  a  right  angle,  and  the  plaster 
east  extending  to  about  the  middle  of  the  thigh.  Soule  has  modified  this 
operation  by  mortisiug  a  piece  of  bone  between  the  divided  halves  of  the 
scaphoid. 

If  the  method  of  inserting  silk  ligatures  does  not  secure  satisfactory 
arthrodesis,  the  joint  surface  should  be  exposed  as  in  excision  and  the 
cartilaginous  surface  removed  from  the  joint.  Albee  advises,  after  exposing 
the  ankle  joint,  the  removal  of  the  astragalus  without  fracturing  it.  The 
cartilaginous  surfaces  of  the  astragalus  are  cut  away  with  a  motor  saw  and 
the  astragalus  is  denuded  of  its  periosteum  and  replaced  in  the  ankle  after 
the  cartilage  has  been  removed  from  the  adjoining  surfaces  of  the  scaphoid, 
OS  calcis,  tibia  and  fibula.  Here  the  astragalus  acts  practically  as  a  bone 
graft  and  makes  bony  ankylosis  of  the  ankle  joint  almost  certain  to  result. 

Dislocation  of  the  patella  is  usually  remedied  by  splitting  the  tendon 
of  the  patella  as  advised  by  Goldthwait.  The  displacement  is  almost  always 
outward  and  while  it  is  easily  reduced,  the  inner  portion  of  the  capsule  has 
become  stretched  and  there  is  a  tendency  to  recurrence  of  the  dislocation. 
An  incision  is  made  to  the  inner  side  of  the  median  line  extending  from  near  the 
middle  of  the  patella  downward  for  about  three  inches.  The  edges  of  the 
wound  are  retracted  and  the  tendon  of  the  patella  is  exposed,  raised,  and 
split  longitudinally.  The  lower  end  of  the  outer  half  of  the  tendon  is  de- 
tached subperiosteally  from  the  tibia,  brought  under  the  inner  half,  and 
reattached  by  quilting  sutures  to  the  periosteum  on  the  inner  portion  of 
the  head  of  the  tibia.    This  prevents  the  tendon  from  sliding  outward. 

Displaced  semilunar  cartilages  are  more  frequent  on  the  inner  side  than 
on  the  outer.  The  knee  is  flexed  at  a  right  angle,  preferably  at  the  end  of  the 
operating  table  according  to  the  method  of  Sir  Robert  Jones  with  the  leg  and 
foot  hanging  down  from  the  table.  An  incision  is  made  going  dowuAvard 
about  half  an  inch  to  the  inner  side  of  the  patella  to  the  tibia  and  then 
curving  at  a  right  angle  along  the  upper  portion  of  the  inner  head  of  the  tibia  for 
about  two  and  a  half  inches.  The  tissues  are  dissected  and  retracted  as  a 
flap  down  to  the  capsule  of  the  joint.  The  fibers  of  the  capsule  are  incised 
without  opening  the  synovial  membrane.  This  membrane  is  then  incised 
parallel  to  the  head  of  the  tibia.  The  inner  semilunar  cartilage  is  elliptical 
in  shape  and  slightly  thicker  than  the  external  semilunar  cartilage.  If  the 
cartilage  is  loose  it  can  be  lifted  with  a  pair  of  forceps  and  dissected  free 
with  scissors  from  its  attachment.  It  is  important  not  to  cut  the  lateral  liga- 
ment of  the  joint.  All  of  the  cartilage  except  a  small  part  of  the  posterior 
portion  is  removed.  The  bleeding  is  checked  by  pressure  of  cotton  sponges 
and  by  whipping  over  the  synovial  membrane  with  a  continuous  catgut  suture. 


414  OPERATIVE    SURGERY 

No  knots  or  exposed  sutures  or  ligatures  should  ever  be  left  "witliiu  the  joint. 
The  capsule  is  brought  together  with  tanned  or  chromic  catgut  and  the  skin 
united  in  the  usual  manner. 

Exposure  of  the  knee  joint  for  removal  of  foreign  bodies,  or  for  removal 
of  a  tumor,  or  inspection  of  the  knee,  is  satisfactorily  done  by  splitting  the 
patella  into  two  halves,  or  by  the  bayonet  incision.  Sometimes  two  lateral 
incisions  may  be  used.  The  splitting  of  the  patella  gives  the  fullest  view 
of  all  the  pouches  and  culdesacs  of  the  joint  and  of  any  repair  work  on  the 
crucial  ligaments  that  may  be  necessary.  The  incision  begins  slightly  to  the 
inner  side  of  the  midline  about  four  inches  above  the  patella  and  extends 
downward  over  the  patella  slightly  to  the  inner  side  of  the  midline  to  a 
point  below  the  insertion  of  the  patella  tendon.  The  tendon  and  the  patella 
are  exposed  and  the  tendon  above  the  patella  is  split  slightly  to  the  inner  side 
of  the  midline,  and  then  is  split  below  the  patella.  The  leg  is  held  straight 
and  the  patella  is  sawed  about  two-thirds  through  when  the  knee  is  flexed 
to  about  forty-tive  degrees  and  the  division  of  the  patella  is  completed  with 
a  sharp  osteotome.  The  patella  is  divided  slightly  to  the  inner  side  of  the 
midline,  because  there  is  less  mobility  of  the  inner  fragments  than  the  outer  and 
better  exposure  can  be  obtained  in  this  way,  as  the  tendons  both  above  and  be- 
low the  patella  are  also  split  a  little  to  the  inner  side  of  the  midline.  The  syno- 
vial membrane  is  opened  above  the  patella,  laying  bare  the  upper  culdesac.  The 
knee  is  then  flexed  about  ninety  degrees  and  the  halves  of  the  patella  are  re- 
tracted strongly  while  the  patella  ligament  is  completely  split  and  the  fat  be- 
neath it  divided.  Any  foreign  body  or  tumor  is  removed,  or  repair  work  is  done 
upon  the  crucial  ligaments  if  necessary.  The  wound  is  closed  by  adjusting  the 
two  halves  of  the  patella  carefully  and  suturing  the  fascia  and  the  split  tendons 
together  so  as  to  hold  the  patella  firmly  approximated.  These  sutures  are  best 
made  of  tanned  or  chromic  catgut.  It  is  not  necessary  to  place  sutures  in  the 
patella  itself.  The  leg  should  be  dressed  in  a  posterior  splint  or  Avith  plaster  of 
Paris  and  gentle  passive  motion  of  the  patella  is  begun  about  the  seventh  day. 

The  knee  may  be  also  exposed  anteriorly  by  the  bayonet  incision,  Avhich 
begins  on  the  inner  side  of  the  patella  about  two  inches  above  it,  is  carried 
down,  then  across  the  ligamentum  patellge  about  half  an  inch  below  the 
lower  border  of  the  patella  and  then  goes  down  along  the  outer  margin  of  the 
ligamentum  patellae.  The  cross  incision  should  not  be  made  at  a  right  angle 
so  that  the  ligamentum  patella  can  be  more  readily  repaired.  This  incision 
requires  longer  for  the  ligamentum  patella  to  repair  and  may  leave  this 
ligament  somewhat  weak. 

If  loose  bodies  are  located  in  the  back  of  the  joint  a  posterior  incision 
may  be  made.  Here  a  long  vertical  incision  is  made  posteriorly  in  the  midline 
beginning  about  three  inches  above  the  joint  and  ending  two  inches  below 
it.  Dissection  is  carried  down  to  the  joint  with  care,  avoiding  the  popliteal 
vessels  and  nerves.    This  incision  is  very  seldom  necessary. 


THE   LOWER   EXTREMITY  415 

Excision  of  the  knee  joint  is  best  done  by  a  sliglitly  curved  anterior  in- 
cision, tliongh  a  U-shaped  incision  with  its  base  upward,  or  an  li-shaped 
incision  can  be  used.  The  U-shaped  incision  has  the  disadvantage  of  poor 
nutrition  at  the  tip  of  the  flap,  which  is  also  an  objection  to  the  H-shaped 
incision.  The  curved  anterior  incision  begins  at  the  posterior  portion  of 
one  of  the  condyles  of  the  femur,  about  half  an  inch  above  the  lowest  articular 
surface,  is  carried  forward  and  slightly  downward  across  the  lower  por- 
tion of  the  knee  and  just  above  the  insertion  of  the  ligamentum  patellae 
and  ends  at  the  posterior  portion  of  the  opposite  condyle  of  the  femur. 
This  incision  is  made  while  the  knee  is  slightly  flexed  and  is  carried 
through  the  ligamentum  patellae  and  the  capsule  of  the  joint,  dividing 
the  ligamentum  patellaj  about  half-way  between  its  insertion  into  the 
tibia  and  the  patella.  The  patella  and  the  tissues  of  the  upper  flap  are 
retracted  upward  and  the  joint  is  further  flexed  while  the  crucial  ligaments 
are  divided.  The  flaps  are  retracted,  the  knee  joint  is  acutely  flexed,  and 
a  section  is  sawed  from  the  femur,  particular  care  being  taken  to  guard  the 
popliteal  vessels.  The  femur  is  held  perpendicular  and  the  saw  is  applied  just 
above  the  articular  line  and  so  far  as  possible  about  parallel  with  the  lower 
plane  of  the  articular  surface  of  the  condyles.  The  articular  surface  of  the 
head  of  the  tibia  is  next  sawed.  The  sections  are  so  sawed  that  the  bone 
surfaces  when  brought  together  Avill  make  a  flexion  of  the  knee  of  about  ten 
or  fifteen  degrees.  This  is  much  better  than  having  an  absolutely  straight 
leg.  It  is  important  not  to  remove  too  much  bone.  If  most  of  the  disease  is  re- 
moved the  other  foci  can  be  chiseled  out.  It  is  important  not  to  use  a  curet  as  this 
may  force  septic  material  into  otherwise  healthy  bone.  The  patella  is  left 
if  it  is  healthy,  or  if  slightly  diseased  its  articular  surface  may  be  removed 
by  a  saw  or  chisel  while  it  is  held  in  bone  forceps.  The  culdesac  under  the 
quadriceps  tendon  is  explored  and  the  synovial  membrane  dissected  away. 
The  bone  is  brought  together  and  fastened  in  position  by  sutures  of  stout 
kangaroo  tendon  through  the  bone  along  the  margins  of  the  incision  and 
by  suturing  the  capsule  and  fascia  with  tanned  or  chromic  catgut.  The  divided 
ligamentum  patellae  is  sutured  with  chromic  catgut. 

An  excellent  method  of  immobilizing  the  surfaces  of  the  bone  after  ex- 
cision of  the  knee  joint  is  the  inlay  graft  of  Albee,  the  technic  of  which 
has  already  been  described.  This  makes  bony  union  more  certain  and  it  may 
be  used  when  it  would  otherwise  appear  necessary  to  remove  a  larger  sec- 
tion of  bone.  It  must  be  recalled  that  the  more  bone  removed  from  the 
femur  above  the  condyles  the  narrower  the  weight  bearing  surface  and  con- 
sequently the  greater  are  the  mechanical  difficulties  of  stabilizing  the  joint. 
It  is  the  practice  of  some  surgeons  to  fix  the  bones  together  by  metal 
nails  or  screws.  These  are  very  likely  to  give  trouble  afterwards.  Irri- 
tating metals,  such  as  iron,  cause  an  osteoporosis  around  the  metal,  and 
so  retard  union.  If  the  bone  cannot  be  held  securely  by  stout  kangaroo  tendon 
it  will  be  best  to  insert  bone  pegs,  which  are  made  from  strips  of  adjacent 


416  OPERATIVE   SURGERY 

Lone  by  the  electric  doweling  instniinciit.  The  inlay  .urat't  method  of  Alhee 
not  only  holds  the  bones  in  position  bnt  adds  to  the  strength  of  tlie  callus. 

The  hip  joint  may  be  excised  by  the  external  straight  incision  of  Lan- 
genbeck,  the  anterior  straight  incision  of  Barker,  or  the  posterior  angular  incis- 
ion of  Kocher.  The  external  straight  incision  begins  over  the  ilium  about 
three  inches  above  the  upper  limit  of  the  great  trochanter  and  is  carried  down 
five  inches  in  the  long  axis  of  the  femur  just  behind  the  center  of  the  outer 
surface  of  the  great  trochanter,  terminating  below  the  base  of  the  great 
trochanter.  The  incision  after  going  through  the  skin  and  fascia  divides  the 
gluteus  maximus  muscle  almost  in  the  line  of  its  fibers.  The  space  between 
the  gluteus  medius  muscle  in  front  and  the  pyriformis  muscle  behind  is  iden- 
tified, widened  by  retraction,  and  the  capsule  of  the  joint  together  with  the 
periosteum  of  the  great  trochanter  is  incised  longitudinally  to  the  bone. 
The  capsule  may  be  further  divided  by  a  transverse  cut.  The  capsule  with 
the  loeriosteum  is  raised  with  a  periosteal  elevator  and  the  cotyloid  ligament 
is  divided  by  inserting  a  stout  knife  between  the  head  of  the  l)one  and  the 
cotyloid  ligament  and  cutting  toward  the  edge  of  the  acetabulum.  In  this 
manner  the  atmospheric  pressure  on  the  joint  is  overcome.  If  there  is  diifi- 
culty  in  doing  this  a  portion  of  the  rim  of  the  acetabulum  is  chiseled 
awa}'.  The  attachment  of  the  muscles  to  the  outer  and  posterior  surface  of  the 
great  trochanter  is  raised  subperiosteally  if  possible  while  the  knee  and  foot 
are  twisted  to  rotate  the  thigh  inward  and  then  to  rotate  the  thigh  outward. 
The  ligamentum  teres  is  divided  and  the  head  of  the  bone  dislocated  by 
maniiDulation  of  the  thigh.  The  upper  end  of  the  femur  is  cleared  of  the  soft 
parts  and  held  with  stout  forceps  while  the  head  of  the  femur  is  sawed  off 
below  the  great  trochanter.  There  should  be  a  slight  obliquity  from  above 
downward  and  inward.  The  acetabulum  is  cleared  by  a  chisel  and  the  pockets 
of  synovial  pouches  are  removed.  A  drainage  tube  is  inserted.  The  capsule 
and  muscles  are  sutured  with  chromic  or  tanned  catgut.  The  limb  is  placed 
in  extension. 

The  anterior  incision  for  excision  of  the  hip  joint  begins  about  half  an 
inch  below  the  anterior  superior  spine  of  the  ilium  and  goes  downward  about 
four  inches  between  the  rectus  and  sartorius  muscles  on  the  inner  side  and 
the  tensor  vagina  femoris  and  gluteal  muscles  on  the  outer  side.  The  lateral 
femoral  cutaneous  nerve  is  retracted  outward  and  so  avoided.  The  inter- 
muscular plane  between  the  muscles  mentioned  is  folloAved  and  the  muscles 
are  retracted  outward  and  inward  respectively.  The  branches  of  the  ex- 
ternal circumflex  will  require  ligation.  The  joint  is  reached  without  the 
actual  division  of  any  other  muscle,  vessel,  or  nerve  of  consequence.  The 
capsule  is  incised  over  the  front  of  the  joint  in  the  line  of  the  incision  and 
down  to  the  head  of  the  femur.  The  cotyloid  ligament  is  cut  to  admit  air 
and  the  neck  of  the  bone  is  divided  with  a  narrow  finger  saAV  or  with  a  wire 
saw  while  retracting  the  soft  parts.  The  head  of  the  bone  is  seized  with 
forceps   and  twisted   out   of  position   after   dividing   the   ligamentum   teres. 


THE   LOWER    EXTREMITY  417 

The  cavity   of  the  aee1iil)iiliim   is  eleared   ol'  any  diseased  material  and  the 
capsule  is  sutured  after  iiisl  ilutiiij^'  drainage. 

The  posterior  angular  incision  of  Kocher  l)egins  at  the  base  of  the  great 
trochanter,  is  ctirried  upward  and  forward  to  the  anterior  angle  of  the  great 
trochanter,  and  then  ol)li(iuely  upward  and  inward  in  the  line  of  the  fibers 
of  the  gluteus  maximus  muscle.  The  aponeurosis  of  the  gluteus  maximus 
muscle  over  the  external  portion  of  the  great  trochanter  is  divided  and  the 
fibers  of  this  muscle  are  divided  in  the  upper  part  of  the  wound  where  the 
branches  of  the  gluteal  artery  must  be  cut  and  tied.  The  interval  between 
the  gluteus  medius  and  minimus  above  and  the  pyriformis  muscle  below  is 
identified  and  retracted  and  the  posterior  part  of  the  capsule  and  of  the 
acetabulum  is  exposed.  The  capsule  is  divided  along  the  upper  border  of 
the  pyriformis  muscle.  The  femur  is  rotated  outward  and  the  insertion  of 
the  gluteus  medius  is  separated  subperiosteally  from  the  bone  externally 
and  the  insertion  of  the  gluteus  minimus  is  similarly  separated  from  the  bone 
along  the  anterior  border  of  the  great  trochanter.  The  insertion  of  the 
pyriformis,  internal  obturator,  and  the  gemelli  muscles  is  similarly  separated 
from  the  great  trochanter  and  the  insertion  of  the  obturator  externus  into 
the  digital  fossa  is  raised  subperiosteally  or  by  a  chisel.  The  thigh  is  rotated 
inward  and  the  inner  and  back  portions  of  the  great  trochanter  are  freed. 
The  cotyloid  ligament  is  divided  to  admit  air.  The  ligamentum  teres  is 
cut  from  behind  on  the  head  of  the  femur  while  the  thigh  is  adducted  and  ro- 
tated inward.     The  head  is  then  dislocated  into  the  wound  and  removed. 

OSTEOTOMY 

Osteotomy  is  often  necessary  to  overcome  deformities  in  the  leg  or  knee. 
It  is  performed  with  an  osteotome  or  a  saw.  If  an  osteotome  is  used  there  should 
be  a  set  of  at  least  three  different  thicknesses.  It  is  important  to  bear 
in  mind  that  an  osteotome  has  a  point  that  is  wedge-shaped  and  not  beveled 
solely  on  one  side  as  a  chisel.  The  osteotome  of  Macewen  is  a  standard  m 
this  respect.  If  a  saw  is  used  it  should  be  either  the  small  finger  saw  or 
else  a  Gigli  wire  saw.  The  Adams  saw  has  a  narrow  cutting  surface  and 
is  shaped  somewhat  like  a  rather  stout  tenotome  with  the  saw  teeth  occu- 
pying the  cutting  portion  of  the  instrument.  The  handle  is  large,  as  in  an 
ordinary  saw,  so  the  instrument  can  be  manipulated  firmly.  Jones'  saw  has 
a  small  button  on  the  tip  of  the  saw  which  will  somewhat  protect  the  soft  tis- 
sue. The  Gigli  wire  saw  surrounds  the  bone  completely.  Through  a  small 
incision  it  is  difficult  to  protect  the  soft  tissues.  The  circular  motor  saw  is 
often  used  with  considerable  advantage,  especially  in  cuneiform  osteotomy, 
when  the  bone  can  be  readily  exposed. 

Linear  osteotomy  is  often  performed  by  what  is  known  as  the  subcutan- 
eous method ;  that  is,  through  a  very  small  incision.  Here  the  section  of  the 
bone  is  guided  largely  by  the  sense  of  touch  with  the  point  of  the  osteotome. 
If  a  wedge-shaped  area  is  removed  the  exposure  of  the  bone  should  be  ample 


418  oim:rativk  surgicry 

aud  the  operation  done  by  sight.  There  is  not  the  same  objection  to  a  longer 
incision  that  formerly  obtained,  and  even  the  linear  osteotomy  can  often 
be  more  satisfactorily  done  by  an  incision  sufficient  to  use  the  sense  of  sight 
as  well  as  of  touch.  In  linear  osteotomy,  as  performed  by  Macewen  for 
knock  knee,  the  outer  side  of  the  knee  and  the  lower  part  of  the  femur  rest 
on  a  sand  bag  which  is  not  too  tightly  filled.  A  longitudinal  incision  is  made 
on  the  inner  side  of  the  thigh,  beginning  half  an  inch  in  front  of  the  tendon 
of  the  adductor  magnus  muscle  and  about  one-half  to  three-fourths  of  an 
inch  above  the  adductor  tubercle.  A  long  scalpel  is  inserted  directly  to 
the  bone  and  cutting  upward  makes  an  incision  down  to  the  periosteum  just 
large  enough  to  admit  the  large  osteotome.  The  osteotome  is  inserted  beside 
the  knife  down  to  the  bone  and  after  it  has  reached  the  bone  it  is  turned  trans- 
versely. The  edge  of  the  osteotome  is  passed  over  the  bone  until  it  reaches 
the  posterior  portion  of  the  internal  border  and  is  driven  in  from  behind 
forward  and  outward.  After  the  cortex  of  the  bone  is  penetrated  a  finer 
osteotome  is  passed  into  the  wound  in  the  bone  alongside  the  osteotome 
already  in  position.  The  wider  groove  left  by  the  first  osteotome  readilj^ 
admits  the  second  one  which  is  thinner.  The  femur  is  bent  with  a  little 
force  and  the  portion  of  its  cortex  that  remains  undivided  is  broken. 
The  osteotome  should  never  be  removed  from  the  bone  until  the  section 
is  complete  and  it  is  best  to  shift  its  position  slightly  after  each  blow 
of  the  chisel  to  prevent  it  from  becoming  bound.  The  osteotome  should 
be  driven  in  such  a  manner  that  it  points  toward  the  surgeon  and  not 
away  from  him,  as  in  this  way  it  can  be  handled  more  satisfactorily.  It 
is  moved  up  and  down  after  each  blow  of  the  mallet  in  order  to  widen  the 
cut.  The  internal  and  posterior  surfaces  of  the  bone  are  first  divided  and 
then  the  osteotome  is  driven  forward  and  outward,  toward  the  front  of  the 
bone.  The  outer  part  and  a  portion  of  the  posterior  surface  remain  undivided 
and  are  fractured.  After  AvithdraAving  the  osteotome  the  wound  is  sutured 
and  dressed  and  the  limb  is  put  up  in  slightly  overcorrected  position  in 
plaster  of  Paris.    This  is  the  typical  operation  of  Macewen  for  knock  knee. 

Cuneiform  osteotomy  requires  a  longer  incision  so  the  bone  can  be  com- 
pletely exposed.  Indeed  there  is  no  serious  objection  to  a  long  incision  in 
the  linear  osteotomy.  If  cuneiform  osteotomy  is  done  over  the  head  of  the 
tibia  the  incision  is  made  and  the  periosteum  is  reflected  Avitli  the  soft  parts. 
The  osteotome  outlines  the  base  of  the  wedge  in  the  cortex  of  the  bone.  The 
base  should  correspond  with  the  angle  of  greatest  deformity  and  should  be 
somewhat  smaller  than  appears  to  be  necessary  as  it  is  easy  to  enlarge  it  if 
it  is  actually  too  small.  The  Avhole  thickness  of  the  bone  is  not  cut  through. 
After  the  wedge  has  been  removed  and  the  limb  straightened  if  a  sufficient 
amount  of  bone  has  not  been  removed,  more  can  be  chiseled  away. 

Osteotomy  by  a  saw  is  usually  done  in  the  neck  of  the  femur.  A  long 
narrow-bladed  knife   is  inserted   about  half   an   inch   above   the   tip   of  the 


TiiM  i,()\vi:u  i;xtri;mity 


419 


troclianler  major,  aiul  pushed  iinvartl  aiul  dowjiwai'd  iiiilil  it  s1rd<es  llic 
neck  of  the  femur  over  wliicli  it  is  passed  at  a  right  angle  to  the  axis  of 
the  neck  of  the  femur,  the  route  being  about  parallel  to  Poupart's  ligament. 
The  knife  is  left  in  this  position  and  an  Adams  or  Jones  saw  is  passed  along 


Fig.   416. — Osteotomy   of   the   neck   of   the   femur  with   the   saw. 

the  side  of  the  knife  until  the  saw  touches  the  neck  of  the  femur.  The  knife 
is  then  removed  and  the  bone  is  divided  with  a  saw  (Fig.  416).  The  saw 
should  not  be  Avithdrawn  until  the  bone  has  been  completely  severed. 


T\eev 


Fig.  417 


Fig.   418 


Fig.   417. — Osteotomy  of  the  internal   condyle  of  the   femur  for  knock  knee.      (Method  of   Ogston.) 
Fig.  418. — Osteotomy  of  the  internal  condyle   of  the  femur  for  knock  knee.      (Method  of  Reeves.) 

In  knock  knee  the  operation  must  be  made  to  suit  the  deformity.  The 
Macewen  operation,  which  has  been  described,  is  satisfactory  when  the  de- 
formity is  in  the  lower  porton  of  the  femur.  If  the  deformity  is  due  to  en- 
largement of  the  internal  condyle  it  may  be  corrected  either  by  Ogston 's 


420  OPERATIVE    SURGERY 

operation  (Fig.  417)  or  by  Reeves'  modification  (Fig.  418).  In  Ogston's 
operation  the  knee  is  fully  flexed  and  a  long  narrow-bladed  knife  is  inserted 
through  the  skin  about  two  or  three  inches  above  the  tip  of  the  internal 
condyle.  The  knife  is  pushed  downward,  forward  and  outward  until  its 
point  is  in  the  intercondyloid  space  when  the  knife  is  turned  with  the  edge 
toward  the  bone  and  is  withdrawn,  cutting  the  soft  structures  to  the  bone. 
An  Adams  saw  is  introduced  through  the  knife  wound  and  divides  the  inner 
condyle  from  above  downward  to  about  three-fourths  of  its  thickness.  The 
leg  is  straightened.  Fracture  of  the  internal  condyle  is  completed  as  the  leg 
is  straightened  and  the  condyle  slips  upward.  Macewen  makes  a  cuneiform 
osteotomy  at  this  point  when  the  defect  is  due  to  an  elongated  internal  con- 
dyle. Osteotomy  of  the  tibia  is  made  at  its  most  prominent  deformity  and 
is  usually  a  cuneiform  osteotomy.  Where  exposure  is  easy  the  circular  electric 
saw  can  be  used  instead  of  the  osteotome. 

ARTHROPLASTY 

Reconstruction  of  an  ankylosed  knee  or  hip  joint  has  been  advocated  by 
the  late  John  B.  Murphy.  These  operations,  however,  have  not  proved  satis- 
factory in  the  knee  for  the  joint  loses  much  of  its  stability  and  the  fascia  that 
is  interposed  is  often  absorbed  from  pressure  and  ankylosis  results.  In 
the  hip  joint  it  is  doubtful  if  sufficiently  satisfactory  results  are  not  obtained 
by  one  of  the  types  of  osteotomy  already  described.  Large  special  instru- 
ments for  boring  out  the  acetabulum  are  necessary. 

The  operation  upon  the  knee  joint,  according  to  Murphy,  was  done  prin- 
cipally through  a  long  external  incision  from  a  point  six  inches  above  the 
knee  joint  to  three  inches  below.  It  is  carried  down  to  the  deep  fascia,  but 
not  through  it  except  over  the  joint  itself.  A  four  inch  vertical  incision  is 
also  made  over  the  inner  side  of  the  knee  joint.  The  patella  is  freed  by 
scalpel  or  chisel,  but  the  quadriceps  tendon  or  the  ligamentum  patellse  is  not 
divided.  The  lateral  ligaments  of  the  knee  joint  are  thoroughly  divided  and 
removed.  If  the  ankylosis  is  marked  and  is  bony  the  bone  is  divided  with 
a  chisel  or  saw  and  the  ends  of  the  femur  and  tibia  are  so  shaped  that  the 
lower  end  of  the  femur  is  convex  and  the  upper  end  of  the  tibia  is  concave 
from  before  backward.  A  large  flap  of  fascia  lata  with  a  thin  layer  of  muscle 
attached  is  dissected  from  the  outer  side  of  the  thigh  through  the  external 
incision  with  the  pedicle  below.  The  flap  is  sufficiently  long  to  pass  through 
the  joint  and  to  envelop  well  the  lower  end  of  the  femur.  It  is  spread  over 
the  lower  end  of  the  femur  and  fixed  in  position  with  a  few  catgut  sutures. 
A  similar  but  smaller  flap  is  passed  between  the  patella  and  the  femur.  The 
wound  is  closed  using  a  small  drainage  and  the  leg  is  immobilized  in  plaster. 
Passive  motion  is  begun  after  a  Aveek.  Most  cases  of  this  type  result  in 
ankylosis,  though  there  may  be  an  occasion  in  which  the  operation  is  justi- 
fiable. 

In  arthroplasty  on  the  hip  the  results  have  been  somewhat  more  satisfac- 


THE   LOWER   EXTREMITY  421 

tory  than  on  the  knee,  tliouoh  it  is  seldom  that  the  indications  for  this  opera- 
tion are  ap])arent.    In  Murphy's  technic  a  V-shaped  incision  is  made  with  the 
trochanter  about  the  center  of  the  V.    The  base  of  the  flap  is  five  inches  wide 
and  is  about  four  inches  above  the  trochanter  and  the  point  about  two  inches 
below   the   trochanter.     The  flap   is   dissected   through   the   skin,   superficial 
fascia  and  fascia  lata  and  retracted  upward.    The  base  of  the  trochanter  major 
is  divided  transversely  by  a  Gigli  wire  saw  or  an  osteotome  and  the  severed 
trochanter  with  the  attached  muscles  is  retracted  upward.     The  capsule  of 
the  joint  is   incised   and   separated   completely   from   the   ilium   around   the 
joint;  then  the  head  of  the  femur  is  chiseled  from  the  acetabulum,  begin- 
ning at  the  line  of  junction  and  saving  as  much  of  the  head  of  the  femur 
as  possible.    After  freeing  most  of  the  head  the  small  remaining  portion  may 
be  fractured.     The  chisels  are  large  curved  chisels,  such  as  carpenters  use, 
and  should  correspond  to  the  curve  of  a  normal  head  of  the  femur.     The 
acetabulum  is  deepened  by  rongeur  forceps  and  chisel  or  by  an  especially 
constructed  large  burr,  which  reams  out  the  cavity.     The  fascia  lata  which 
was  turned  up  with  the  V-flap  is   dissected  from  the   skin,   placed   in  the 
acetabulum,  and  held  in  position  by  a  few  interrupted  sutures  of  chromic 
catgut.     The  head  of  the  femur  is  so  shaped  and  smoothed  by  rongeur  for- 
ceps or  by  a  concave  reamer  that  it  will  fit  loosely  into  the  acetabulum  before 
the  flap  of  fascia  lata  is  turned  down,  and  snugly  after  the  fascia  lata  has 
been  placed  in  position.    Every  part  of  the  new  articulating  surface  is  covered 
with  fascia.    It  takes  only  the  part  of  the  flap  near  the  base  to  line  the  ace- 
tabulum and  the  apex  is  used  to  cover  the  femur.     This  is  also  fastened  in 
position  by  interrupted  catgut  sutures  inserted  into   the  periosteum  of  the 
neck  of  the  femur  and  into  the  edges  of  the  fascial  flap.     The  trochanter 
major  is  then  returned  and  fixed  in  position  by  a  wire  suture  or  a  bone  peg. 
The  wound  is  closed  and  the  leg  placed  in  extension.     It  may  be  necessary 
before  closing  the  wound  to  do  a  tenotomy  on  the  tendons  and  muscles  that 
are  too  greatly  contracted  to  permit  the  thigh  being  placed  in  its  natural 
position. 

OSTEOMYELITIS 

The  type  of  operation  for  osteomyelitis  depends  largely  upon  the  stage 
of  the  inflammation.  Many  limbs  have  been  needlessly  sacrificed,  because 
the  diagnosis  of  rheumatism  or  growing  pains  has  been  made  and  persisted 
in  until  there  has  been  extensive  damage.  The  x-ray  is  the  greatest  help 
in  making  an  early  diagnosis  because  as  it  has  already  been  pointed  out 
in  discussing  surgery  of  the  bones,  irritating  substances  cause  a  rapid  absorp- 
tion of  lime  salts  for  it  is  nature's  effort  to  remove  this  rigid  material  which 
is  an  obstacle  to  the  hyperemia  that  is  necessary  to  combat  inflammation.  Bone, 
therefore,  is  converted  as  nearly  as  possible  into  soft  tissue  so  that  mul- 
tiplication and  dilatation  of  the  blood  vessels  may  be  unhampered  by  any 
rigid  structure.  The  x-rays  should  in  the  early  stages  show  a  light  spot 
where  the  inflammation  has  begun.     Any  child  who,   after  a  slight  injury 


422  OPERATIVE    SURGERY 

or  exposure  to  cold,  has  marked  pain  near  the  knee  or  ankle,  particularly 
if  there  is  a  chill  or  fever,  should  be  regarded  as  at  least  suspicious  of 
having  osteomyelitis  and  if  the  roentgenogram  confirms  the  suspicion,  opera- 
tion should  be  done  as  soon  as  possible.  It  is  well  to  mark  the  point  of 
greatest  tenderness  before  giving  an  anesthetic. 

In  order  to  recognize  the  structures  it  is  best  to  use  a  tourniquet.  A 
free  incision  is  made  over  the  affected  bone,  taking  care  to  avoid  opening  into 
the  neighboring  joint.  Due  regard  is  paid  to  vessels  and  nerves.  The  sub- 
cutaneous surface  of  the  tibia  is  the  best  place  for  the  incision  in  the  leg. 
In  the  thigh  the  outer  portion  of  the  thigh  in  front  of  the  biceps  tendon 
or  between  the  biceps  tendon  and  the  iliotibial  band  is  the  preferable  area 
for  incision.  In  very  early  stages  there  will  be  no  marked  change  in  the 
tissues  over  the  bone,  or  in  the  periosteum,  except  an  increased  hyperemia, 
but  soon  after  the  beginning  of  the  disease  the  tissues  become  edematous 
and  the  periosteum  is  thickened,  soft,  and  frequenth'  loosely  attached.  After 
separating  the  periosteum  from  the  bone  over  an  area  of  about  an  inch, 
the  bone  is  carefully  examined  for  evidence  of  perforation  and  a  grooved 
director  is  passed  around  the  bone  to  the  popliteal  space,  if  the  femur  is 
being  explored,  as  often  pus  collects  in  this  region.  With  a  burr  or  a  drill 
the  cortex  of  the  bone  is  perforated  and  the  medulla  is  opened  near  the  epi- 
physeal line.  Usually  pus  will  be  recognized  after  the  cortex  has  been  pene- 
trated; but  if  not,  the  opening  in  the  cortex  is  sufficiently  enlarged  with 
rongeur  forceps  to  enable  the  surgeon  to  explore  the  bone  more  thoroughly.  In- 
jury to  the  epiphyseal  cartilage  must  be  avoided.  As  soon  as  pus  is  dis- 
covered the  focus  is  removed  Avith  a  curet  and  the  cavity  of  the  bone  filled 
with  pure  carbolic  acid,  which  is  permitted  to  stand  for  about  a  minute 
and  is  then  washed  out  with  alcohol.  Drainage  is  best  accomplished  with 
a  rubber  tube,  together  with  loose  packing  of  iodoform  gauze.  A  dressing  and 
a  splint  are  applied. 

If  no  focus  is  found  it  is  best  to  make  provision  for  drainage  because 
it  may  be  probable  that  the  focus  is  present  but  has  not  been  discovered  and 
the  drainage  will  prevent  tension  and  attract  the  inflammatorj^  process  to 
itself  because  of  the  effort  to  extrude  the  drainage  by  the  lymphatic  current. 
In  later  stages  pus  is  often  found  under  the  periosteum,  but  this  merely 
means  that  there  has  been  extension  from  the  osteomyelitis.  Suppurative 
periostitis  without  an  external  Avound  is  exceedingly  rare  and  in  the  vast 
majority  of  cases  the  cause  of  the  pus  is  from  inflammation  Avithin  the  bone. 
After  cleaning  aA\^ay  the  pus  under  the  periosteum  a  fistula  that  may  lead 
within  the  bone  is  sought  for  and  if  it  is  impossible  to  find  it,  or  if  it  is  im- 
practicable to  folloAv  it,  the  bone  should  be  opened  as  has  already  been  de- 
scribed. 

In  the  later  stages  of  osteomyelitis  there  may  be  an  extensive  amount  of 
destruction  of  the  bone,  and  an  iuA^olucrum  results;  or  the  infection  maA^  be 
mild  and  the  resistance  of  the  patient  effectiA-e  and,  conpequently,  the  inflam- 
mation Avill  be  located  in  a  small  area  Avith  comparatively  little  destruction  of 


THE    LOWER    EXTREMITY  423 

tlie  bone.  Here  tlic  boiic  is  oixmkhI  after  exi)osiiig  and  retracting  the  peri- 
osteum. Ilie  diseased  l)oiie  is  removed  by  a  cliisel  and  the  wound  disinfected 
with  pure  carbolic,  wliich  is  left  for  a  minute  and  then  removed  and  the 
wound  flushed  with  alcohol,  and  cleaned  with  peroxide  of  hydrogen.  In 
such  instances  the  wound  may  be  dried  and  filled  with  a  plug  or  filling.  It 
is  essential,  however,  that  the  cavity  of  the  bone  be  dry.  The  tourniquet 
should,  of  course,  remain  in  position  during  the  operation.  The  cavity  of 
the  bone  is  dried  Avith  gauze  sponges,  or  better  still,  by  a  hot  air  blast.  If 
the  hot  air  blast  is  not  available  the  actual  cautery  can  be  held  in  the  cavity, 
though  not  in  contact  with  the  bone  for  this  will  cause  more  dead  bone.  Af- 
ter the  cavity  has  been  thoroughly  dried  Mosetig-Moorhof 's  filling  is  melted 
and  poured  in  up  to  the  level  of  the  periosteum.  The  periosteum  is  brought 
together  loosely  Avith  sutures  of  catgut  after  the  plug  has  become  partially 
solidified.  The  subcutaneous  tissues  are  sutured  with  catgut,  and  the  skin 
with  sillvAvorm-gut. 

The  ]\Iosetig-Moorhof  plug,  which  seems  to  have  stood  the  test  better  than 
any  of  the  substitutes,  is  made  as  follows:  The  proportions  consist  of  60 
parts  of  iodoform,  40  parts  of  si^ermaceti  and  40  narts  of  oil  of  sesame. 
These  ingredients  are  mixed  and  sloAvly  heated  to  212°  F.  on  a  Avater  bath 
and  then  alloAved  to  cool  Avhile  being  shaken.  When  ready  for  use  the  mass 
is  heated  to  about  122°  F.,  Avhich  melts  it,  and  is  constantly  shaken  or  stirred 
to  keep  the  iodoform  equally  distributed.  The  heating  should  be  done  by 
placing  the  container  in  hot  Avater.  The  melted  mass  is  poured  into  the  Avound 
at  about  115°  to  120°  F.,  the  leg  or  thigh  being  held  in  such  a  position  that 
the  margins  of  the  Avound  in  the  bone  will  be  horizontal.  Care  must  be  taken 
before  applying  the  plug  that  every  recess  of  the  diseased  bone  has  been 
cleansed  and  dried,  as  Avell  as  disinfected.  This  filling  is  not  suited  for  acute 
osteomyelitis,  because  here  the  reaction  of  tissue  is  so  great  and  the  infec- 
tion is  so  virulent  that  nothing  short  of  drainage  Avill  be  adequate.  After 
drainage  for  a  fcAV  Aveeks,  hoAvever,  the  Mosetig-Moorhof  plug  can  often 
be  used  to  fill  the  cavity.  Frequently  some  of  the  plug  is  extruded  between 
the  lines  of  sutures,  as  the  cavitv  fills  in  Avith  granulations.  Occasionally  th^s 
does  not  happen  and  the  wound  heals  superficially,  the  bone  plug  being  grad- 
uallv  absorbed.  For  months  and  years  after Avards,  during  the  absorption 
of  the  plug,  traces  of  iodine  can  be  detected  in  the  urine.  This  does  not 
apparently  injure  healthy  kidneys,  but  if  any  nephritis  Avas  present  before 
the  osteomyelitis  occurred  there  might  be  some  danger  in  using  the  plug, 
and  here  packing  Avith  gauze  is  probably  the  best  treatment. 

Aside  from  any  other  consideration  the  use  of  a  bone  filling  saves  the 
patient  many  dressings  and  considerable  pain  and  results  in  a  more  symmetri- 
cal bone,  even  if  part  of  the  filling  is  extruded,  as  frequently  happens.  It 
merely  requires  a  superficial  dressing  and  this  is  a  great  advantage  over  the 
almost  daily  packing  of  a  deep  and  tortuous  Avound  in  the  bone. 

If  a   considerable  mass  of  bone  has  been  killed  by  the   inflammation   a 


424  OPERATIVE    SURGERY 

sequestrum  forms  and  around  it  is  built  up  layers  of  living  bone,  Avliich 
enclose  the  sequestrum,  and  this  is  called  the  iuvolucrum.  If  the  operation 
is  done  in  the  early  stage  and  the  pressure  that  accompanies  inflammation 
is  removed  before  the  septic  products  are  scattered  extensively  through  the 
medullary  cavity  of  the  bone,  the  formation  of  a  sequestrum  may  be  prevented 
unless  the  infection  is  very  virulent  or  the  patient's  resistance  is  at  a  low 
ebb.  If  a  sequestrum,  hoAvever,  has  formed,  the  time  for  operation  for  its 
removal  should  be  chosen  v^^ith  considerable  care.  During  the  very  acute 
stages,  even  if  a  sequestrum  is  forming,  operation  is  unwise  except  to  relieve 
pressure  and  institute  drainage,  because  the  raw  surfaces  of  the  bone  that  are 
necessarily  left  after  an  operation  will  become  infected  from  the  inflamma- 
tion and  the  destruction  of  more  bone  will  of  necessity  be  repeated.  After 
the  virulence  of  the  inflammation  has  subsided,  and  particularly  if  the  dead 
bone  is  well  separated  from  the  living  bone,  operation  should  be  performed 
as  soon  as  possible,  because  the  continued  presence  of  the  dead  bone  merely 
acts  as  a  refuge  and  a  culture  medium  for  bacteria  and  septic  products. 


Fig.    419. — The    dark    portion    of    the    iuvolucrum    shows   the    part    to    be    removed    in    order    to    avoid    cavity 

formation   in   the   bone. 

In  chronic  cases,  when  the  iuvolucrum  is  weak,  it  may  be  wise  to  estab- 
lish drainage  and  keep  the  wound  clean  until  the  iuvolucrum  has  become  suffi- 
ciently strong  to  hold  the  general  shape  of  the  bone.  As  a  rule,  however, 
when  the  sequestrum  is  sharply  marked  from  its  surrounding  adjacent  bone 
the  iuvolucrum  is  sufficiently  firm  to  hold  the  general  contour  of  the  bone 
after  removal  of  the  sequestrum.  Where  there  are  two  bones,  as  in  the  leg 
and  forearm,  the  sequestrum  can  be  removed  earlier  because  the  healthy  bone 
acts  as  a  splint.  The  periosteum  is  stripped  from  the  dead  bone  together 
with  adherent  cortical  cells  of  bone  and  folded  over  after  disinfecting  the 
cavity  from  which  the  diseased  bone  was  removed.  The  wound  can  then  be 
closed  with  the  expectation  that  the  periosteum  and  its  thin  layer  of  cambium 
bone  will  reproduce  the  shaft.  E.  H.  Nichols,  of  Harvard,  has  done  excel- 
lent work  along  this  line  and  has  shown  that  there  are  stages  in  osteomyelitis 
in  which  the  periosteum  will  produce  bone  very  much  more  readily  than  at 
other  times. 

The  removal  of  a  sequestrum  is  merely  an  extended  form  of  the  operation 
that  has  already  been  described.     A  tourniquet  is  used  and  the  incision  is 


THE   LOWER   EXTREMITY 


425 


sufficiently  long  to  enable  the  sequestrum  to  be  removed  and  the  cavity 
from  which  it  has  come  to  be  explored  thoroughly.  The  tibia  is  the  bone  on 
which  the  operation  of  sequestrotomy  is  most  frequently  performed.  After 
applying  the  tourniquet  an  incision  is  made  the  length  of  the  diseased  bone 
and  the  periosteum  is  divided,  stripped  up,  and  retracted.  The  involucrum 
over  the  sequestrum  is  usually  thin  and  soft,  but  portions  of  it  may  be  firm. 
It  is  removed  with  rongeur  forceps,  or  with  a  chisel  and  mallet  so  that  the 
sequestrum  and  every  portion  of  the  cavity  containing  it  can  be  thoroughly 
explored.  If  it  is  practical  to  do  ^so  it  is  Avell  to  remove  one  wall  of  the 
involucrum,  saving  if  possible  the  crest  of  the  bone  if  it  is  the  tibia,  as  this 
is  the  strongest  portion.  If  one  wall  is  completely  removed  the  soft  tissues 
can  fill  in  the  cavity  and  this  will  greatly  hasten  the  process  of  healing 
(Fig.  419).  A  small  portion  of  healthy  cortical  bone  left  adherent  to  the 
periosteum  is  sufficient  to  reproduce  the  shaft  of  the  bone  satisfactorily  if 
a  splint  is  applied  and  the  bone  is  protected  from  strain  during  convalescence. 


- 

,^ 

i  ■ 

^^^ 

"1  ■- 

L  ^:>> 

Fig.   420. 


Fig.    421. 


Fig.    420. — Another   method    of    avoiding    cavity    formation    in    the    bone.      One    wall    of    the    involucrum    has 

been   mobilized. 
Fig.  421. — The  mobilized  wall  of  the  involucrum  shown  in  the  preceding  figure  is  so  folded  as  to  obliterate 

the   cavity  in  the  bone. 


After  removing  the  sequestrum  and  a  portion  of  the  involucrum  the  cavity  is 
curetted  and  cleaned  with  gauze  and  peroxide.  The  cavity  may  then  be  dis- 
infected with  pure  carbolic  which  is  followed  by  alcohol,  or  tincture  of  iodine 
may  be  applied.  If  it  is  quite  certain  that  all  the  diseased  bone  has  been 
removed  the  wound  may  be  closed,  filling  space  that  cannot  otherwise  be 
obliterated  with  the  Mosetig-Moorhof  bone  plug.  Some  surgeons  prefer 
using  salt  solution  and  suturing  the  soft  parts  to  prevent  its  escape.  Some- 
times in  neglected  cases,  the  involucrum  is  so  dense  that  it  does  not  seem 
practicable  to  remove  a  sufficient  amount  to  bring  in  the  soft  tissues.  Here 
the  Mosetig-Moorhof  plug  may  be  utilized,  or  one  of  several  plastic  proce- 
dures can  be  done.  One  wall  of  the  involucrum  may  be  so  separated  and 
mobilized  that  it  will  fall  in  on  the  cavity  (Figs.  420  and  421).  The  over- 
lying soft  parts  may  be  undermined  and  fastened  to  the  depth  of  the  wound 
by  pegs  or  sutures.  This,  however,  leaves  a  furrow  and  a  marked  deform- 
ity, which  is  objectionable.     Grafting  of   soft  parts  into   the   wound  by   a 


426 


OPERATIVE   SURGERY 


pedunculated  flap  can  be  done  according-  to  the  operation  of  von  Eiselsberg. 
According  to  this  method  if  the  defect  is  in  the  lower  part  of  the  tibia  a 
flap  with  its  base  downward  is  fashioned  over  the  upper  part  of  the  tibia 
after  the  lower  defect  has  been  prepared  by  a  curet  and  chisel  and  the  flap 
which  includes  the  skin,  periosteum,  and  the  whole- thickness  of  the  cortical 
bone  attached  to  the  periosteum  is  turned  doAvn  into  the  defect  (Figs.  422, 
423  and  424).     Care  must  be  taken  not  to  twist  the  pedicle  too  greatly.     The 


Fig.  422. — Lines  of  incision 
for  flap  to  fill  defect  in  the  bone, 
(von    IJiselsberg.) 


Fig.   423.— The   flap   has   been   mo-  i-ig.   4.^:4.— The   flap   is  sutured 

bilized    and    is    ready    to    be    turned         in    position.       (von    Eiselsberg.) 
down  in  position,     (von  Eiselsberg.) 


defect  in  the  upper  part  of  the  wound  is  closed  as  far  as  possible  by  under- 
mining and  sliding  the  skin. 

Transplantation  of  fat  into  a  defect  of  the  bone  after  the  cavity  has  be- 
come sterile  has  been  done  with  some  success.  Portions  of  adjacent  muscle 
may  also  be  utilized  as  a  filling  if  there  is  but  little  tendency  to  reproduce 
bone.  It  is  best  to  graft  bone  only  after  the  cavity  has  become  clean,  follow- 
ing the  technic  of  bone  grafting  that  has  already  been  described. 


THE   LOWER   EXTREMITY 


427 


ELEPHANTIASIS 

Obstruction  of  the  inaiii  lyinpliatie  trunks  from  the  leg  causes  swelling 
of  tlie  lower  extremity  which  may  assume  enormous  proportions.  This  swel- 
ling is  not  the  result  of  interference  w^ith  the  blood  circulation,  but  is  due 
solely  to  obstruction  in  the  lymph  current.  These  cases  of  elephantiasis  are 
often  satisfactorily  treated  by  the  operation  of  Kondoleon,  of  Greece,  Avho 
eiuloavors   to   secure   an   anastomosis   between   the    superficial    and    the    deep 


S>JTTvpV>y3>.3 


Fig.  425. — lyines  of  incision  for  operation  of 
Kondoleon  on  outer  surface  of  the  lower  ex- 
tremity. 


Fig.  426. — lyines  of  incision  for  operation  of 
Kondoleon  on  inner  surface  of  the  lower  ex- 
tremity. 


lymphatic  systems  of  the  leg,  as  the  obstruction  that  produces  the  swelling 
seems  to  be  chiefly  if  not  entirely  in  the  lymphatics  that  drain  the  skin  and 
deep  fascia  of  the  leg  and  thigh.  This  operation  has  been  used  with  consid- 
erable success  by  Matas,  Royster,  Hill  and  Sistrunk.  Sistrunk  has  modified 
the  operation  by  making  it  somewhat  more  extensive  and  removing  a  consid- 
erable amount  of  tissue. 

Long  incisions  are  made  on  the  outer  and,  if  necessary,  on  the  inner  sur- 
face of  the  leg  and  thigh,  extending  externallj'  from  just  below  the  trochanter 


428  OPERATIVE   SURGERY 

major  to  just  above  the  external  malleolus  (Figs.  425  and  426).  A  large 
slice  of  the  edematous  fat  is  removed  and  the  fascia  is  opened  down  to 
the  muscle.  A  strip  of  fascia  about  two  inches  wide  is  excised  and  the 
edges  of  the  fascia  are  fastened  to  the  muscle  by  interrupted  sutures 
of  catgut  in  order  to  fix  the  fascia  in  position.  The  edges  may  be  tucked 
in  at  the  point  of  suture  and  in  this  way  Avill  probably  prevent  the  rapid 
reunion  of  the  fascia.  The  skin  is  closed  with  a  continuous  suture  of 
tanned  or  chromic  catgut  or  with  silk.  The  skin  and  fat  should  come  together 
over  the  exposed  muscle.  If  the  incision  in  the  outer  portion  of  the  leg  and 
thigh  does  not  relieve,  an  incision  on  the  inner  side  can  be  made  a  month 
or  two  later.  Here  the  incision  is  made  from  a  point  near  the  perineum 
directly  down  to  just  above  the  internal  malleolus.  A  mass  of  fat  is  re- 
moved and  a  strip  of  fascia  lata  is  excised,  the  edges  of  the  fascia  being  fas- 
tened to  the  muscle  as  after  the  external  incision.  The  skin  being  closed  with 
continuous  sutures  without  drainage.  By  careful  hemostasis  but  little  blood 
is  lost  and  the  anastomosis  between  the  deep  and  the  superficial  lymphatics  is 
usually  so  satisfactory  as  to  result  in  a  cure. 

The  patient  should  wear  a  support  and  promote  the  lymphatic  circulation 
by  hot  applications  and  massage  for  several  weeks  after  the  operation. 

VARICOSE  VEINS 

The  type  of  oj^eration  for  removal  of  varicose  veins  of  the  leg  depends 
upon  the  extent  and  the  location  of  the  diseased  veins.  There  are  three  forms 
of  veins  in  the  lower  extremity:  (1)  those  without  valves  in  which  the 
blood  may  run  either  way,  (2)  veins  in  which  the  valves  direct  the  blood 
toward  the  surface,  and  (3)  veins  in  which  the  valves  direct  the  blood  toward 
the  deep  veins.  The  perforating  branches  that  connect  the  deep  and  super- 
ficial veins  are  most  numerous  in  the  middle  and  lower  part  of  the  leg.  In 
the  middle  of  the  leg  these  perforating  branches  are  surrounded  by  muscles 
and  consequently  the  superficial  veins  are  frequently  the  first  to  dilate  at 
different  points,  because  the  bulk  of  the  muscles  prevents  drainage  into  the 
deep  veins.  The  subcutaneous  ligation  that  was  formerly  practiced  is  not 
now  considered  satisfactory  and  division  or  excision  of  the  vein  gives  better 
results.  The  veins  may  be  divided  and  ligated  in  the  thigh,  excising  a  por- 
tion of  the  main  trunk,  or  a  circular  incision  can  be  made  beloAv  the  knee  and 
multiple  ligations  done  on  the  divided  veins. 

Schede  encircles  the  leg  with  an  incision  about  the  junction  of  the  upper 
and  the  middle  thirds,  cutting  all  tissues  down  to  the  deep  fascia,  tying  both 
ends  of  the  divided  veins,  and  suturing  the  skin.  Friedel,  after  ligating  the 
long  saphenous  in  the  thigh,  makes  a  spiral  incison,  beginning  below  the 
knee  and  encircling  the  leg  several  times  ending  the  incision  on  the  back  of 
the  foot.    All  veins  are  tied,  but  the  wound  is  left  open. 

Trendelenburg  ligates  and  resects  the  saphenous  vein  in  three  places, 
in  the  middle  of  the  thigh,  and  above  and  below  the  internal  condyle.     Total 


THE   IjOWER   extremity 


429 


resection  in  the  tliigli  can  be  accomplished  through  a  long  incision  from  the 
saphenous  opening  to  the  posterior  border  of  the  internal  condyle  and  this 
may  be  continued  to  the  internal  malleolus.  The  scar  at  the  knee,  however, 
is  often  an  annoyance  and  if  an  ulcer  is  present  the  incision  should  not  extend 
to  it,  so  as  to  avoid  infection  in  the  wound. 

The  operation  of  C.  H.  Mayo  is  simpler  and  avoids  extensive  scarring  of 
the  skin.     He  uses  multiple  short  incisions  over  the  course  of  the  vein    be- 


Fig.   427.— Lines   of  incision   for  excision   of  varicose  veins   of  the   leg. 

ginning  just  below  the  saphenous  opening.  The  vein  is  doubly  ligated,  di- 
vided and  its  distal  portion  stripped  subcutaneously  as  far  as  possible  (Fig. 
427).  This  may  be  done  by  threading  the  distal  end  of  the  vein  through  an 
instrument  devised  by  C.  H.  Mayo  called  a  ''vein  stripper."  Instead  of  the 
vein  stripper  a  medium-sized  blunt  uterine  curet  can  be  used  satisfactorily. 


430 


0['ER;\.TIVE    SURGERY 


When  tlie  stripping  has  been  cariied  as  far  down  Die  tliigh  as  possible  the  end  of 
the  vein  stripper  is  cut  doAvn  upon  and  the  vein  is  brought  up  into  a  short 
incision  and  loosened  from  the  tissues  in  its  neighborhood.  The  vein  strip- 
per through  which  the  vein  is  still  threaded  is  again  pushed  down  beneath 
the  skin  to  a  point  below  the  knee  if  possible,  and  is  again  cut  down  upon 
(Fig.  428).  This  avoids  making  an  incision  on  a  level  with  the  knee  joint. 
The  vein  is  brought  up  through  this  last  incision  and  ligated  below.    It  is  not 


Fig.    428. — Mobilizing    a    varicose    vein    and    stripping    it    from    one    incision    to    the    other    by    method    of 

C.  H.   Mayo. 

possible  to  use  the  vein  stripper  much  below  the  knee  because  the  varicose 
veins  here  are  very  large  and  the  branches  are  numerous.  Along  the  inner 
side  of  the  leg  an  incision  is  made  either  straight  or  curved  and  fashioned 
to  give  the  maximum  exposure  of  the  veins,  and  the  veins  are  excised.  If  an 
ulcer  is  present  it  should  be  protected  by  gauze  during  the  progress  of  the 
operation  on  the  veins  and  after  this  has  been  completed,  the  ulcer  may  be 
excised  and  the  raw  surface  skin  grafted  with  Thiersch  grafts. 


THE  SCIATIC  NERVE  AND  BRANCHES 

The  technic  of  operations  upon  nerves  has  already  been  described,  but 
on  account  of  wounds  or  tumors  it  may  be  necessary  to  expose  the  sciatic 
nerve  or  its  two  main  branches,  the  tibial  and  the  common  peroneal.  In  ex- 
posing the  sciatic  nerve  for  stretching   or   other  purposes   the  patient  lies 


THE  IjOwer  extremity  431 

prone.  The  tuberosity  of  tlie  isehiiuu  autl  tlie  great  troehaiiter  are  identified 
and  an  incision  is  made  midway  between  these  points  and,  beginning  just  above 
the  gluteal  fold,  it  goes  down  the  leg  for  about  four  or  five  inches.  The  small 
sciatic  nerve  is  then  seen.  The  lower  edge  of  the  gluteus  maximus  will  be 
found  about  the  middle  of  the  incision.  The  hamstring  muscles  are  demon- 
strated by  bending  the  knee  so  as  to  identify  them  and  are  retracted  iuAvard. 
The  nerve  is  a  little  nearer  to  the  tuberosity  of  the  ischium  than  to  the 
great  trochanter.  In  exposing  the  upper  portion  of  the  sciatic  for  suturing, 
the  incision  is  more  extensive.  The  lower  part  of  the  incision  is  vertical 
as  is  made  for  stretching  the  nerve,  but  at. the  gluteal  fold  it  curves  sharply 
outward  along  the  outer  border  of  the  gluteus  maximus  and  is  carried  to 
the  level  of  the  tip  of  the  trochanter  major,  or  higher  if  necessary.  A  flap 
is  reflected  and  turned  inward,  exposing  the  upper  portion  of  the  sciatic 
nerve.  This  incision  tends  somewhat  to  prevent  infection  and  gives  a  satis- 
factory scar.  The  internal  popliteal  or  tibial  nerve,  as  it  is  now  called,  is 
exposed  by  an  incision  that  begins  opposite  the  center  of  the  popliteal  space 
and  is  carried  three  and  one-half  inches  downward  between  the  two  heads 
of  the  gastrocnemius  muscle.  The  short  saphenous  vein  and  the  small  nerve 
are  retracted  and  after  dividing  the  deep  fascia  the  two  heads  of  the  gastroc- 
nemius are  separated.  The  short  saphenous  vein  empties  into  the  popliteal 
vein  beneath  the  nerve,  the  tibial  nerve  being  most  superficial,  the  vein  next 
and  the  artery  nearest  the  joint.  The  external  popliteal  or  common  peroneal 
nerve  follows  the  outer  side  of  the  popliteal  space  and  lies  close  to  the  biceps. 
The  nerve  passes  over  the  outer  head  of  the  gastrocnemius  muscle,  lying  be- 
tween it  and  the  biceps,  and  crosses  the  fibula  just  below  its  head  beneath 
the  upper  fibers  of  the  peroneus  longus  muscle.  When  the  knee  is  flexed  the 
nerve  may  be  easily  felt  just  behind  the  biceps  tendon.  The  incision  to  ex- 
pose the  nerve  is  about  two  inches  long  and  runs  along  the  posterior  border 
of  the  tendon  of  the  biceps  from  behind  the  prominence  of  the  external 
condyle  of  the  femur  toward  the  posterior  border  of  the  head  of  the  fibula. 
The  biceps  tendon  is  exposed  and  the  knee  is  flexed  to  relax  the  tendon. 
The  nerve  lies  near  the  attachment  of  the  biceps  tendon  to  the  head  of  the 
fibula,  between  this  point  and  the  outer  edge  of  the  gastrocnemius  muscle. 
Care  must  be  taken  to  identify  the  biceps  tendon  as  sometimes  a  band  of 
fascia  may  simulate  this  tendon. 


CHAPTER  XX 
OPERATIONS  ON  THE  THORAX  EXCEPT  THE  MAMMARY  GLAND 

THE  RIBS 

Operations  upon  the  ribs  are  done  in  two  types  of  cases :  (1)  those  in  which 
there  is  a  disease  of  the  rib  itself  and  the  operation  is  designed  to  remove 
the  disease  by  removing*  the  rib,  and  (2)  those  in  which  a  healthy  rib  is  re- 
moved to  gain  access  to  the  contents  of  the  thorax,  to  mobilize  the  chest 
wall  to  fill  a  cavity,  as  after  chronic  empyema,  or  in  cardiolysis  when  the 
rigid  ribs  hold  the  adherent  heart  and  it  is  necessary  to  mobilize  the  chest 
wall  over  the  heart. 

Operations  for  tumors  involving  the  chest  wall  or  ribs  cannot,  of  course, 
be  typical,  but  whenever  the  pleura  is  opened  certain  definite  procedures 
must  be  folloAved.  The  most  important  of  these  is  to  avoid  sudden  collapse 
of  the  lungs.  This  accident  is  serious  if  there  is  a  wdde  opening  in  the  chest 
and  the  mediastinum  is  not  rendered  immobile.  The  late  John.  B.  Murphy 
called  attention  to  this  danger  and  the  necessity  for  fixing  a  collapsed  lung 
by  grasping  it  with  forceps  in  order  that  the  diaphragm  may  act  satisfac- 
torily. 

The  chest  may  be  considered  as  two  barrels  of  a  syringe,  the  midline  repre- 
senting a  flexible  partition  between  the  two  barrels.  If  the  diaphragm  is 
likened  to  the  piston  of  a  syringe  it  can  easily  be  seen  that  but  little  change 
in  pressure  can  be  induced  in  either  barrel  by  the  ascent  or  descent  of  the 
piston  if  there  is  a  large  opening  in  one  of  the  cylinders  of  the  syringe  and 
at  the  same  time  the  partition  between  the  two  cylinders  is  so  flexible  that 
it  readily  flaps  to  either  side.  If,  hoAvever,  the  partition  is  held  rigid,  suc- 
tion can  be  made  in  the  unopened  compartment  by  descent  of  the  piston,  or 
compression  by  ascent. 

So  the  action  of  the  diaphragm  is  embarrassed  by  a  large  opening  in 
one  pleura.  If  both  pleural  cavities  communicate  with  each  other,  which 
is  uncommon  in  man,  but  common  in  some  of  the  lower  animals,  the  prog- 
nosis is  much  more  serious.  If  the  opening  into  the  pleura  is  small  and 
can  be  closed  by  a  pad  the  embarrassment  of  respiration  is  greatly  re- 
lieved, if  not  done  away  with,  because  the  pleural  cavity  being  filled  with 
air  and  the  opening  into  the  pleura  closed,  the  median  partition  is  stabilized 
and  respiration  goes  on  satisfactorily.  A  hole,  however,  through  which 
the  air  rushes  in  and  out  produces  a  flapping  back  and  forth  of  the  median 
partition  between  the  pleural  cavities  and  almost  nullifles  the  function  of 
the  diaphragm.  In  injuries  of  the  pleura,  then,  the  opening  must  either  be 
closed  as  soon  as  possible,  or  else  the  collapsed  lung  must  be  caught  with 

432 


THE    THORAX  433 

rubber-covered  clamps  or  gauze  and  held  firmly  during  some  necessary  ma- 
nipulation so  that  the  median  partition  is  stHl)ilized  and  the  lung  of  the  un- 
opened pleura  can  expand  and  contract  during  respiration. 

In  operations  for  removal  of  sections  of  the  chest  wall  including  the 
ribs,  a  differential  pressure  cabinet  was  formerly  employed  in  which  the 
patient's  head  and  neck  were  placed  in  a  cabinet  with  increased  atmospheric 
pressure,  and  so  the  danger  of  collapse  of  the  lung  was  avoided.  These 
cabinets  were  expensive,  complicated,  and  unsatisfactory  and  the  simpler 
method  of  Metzer  and  Auer  who  introduced  intratracheal  anesthesia  is  much 
more  satisfactory.  Modifications  have  been  numerous.  Samuel  Kobinson 
devised  an  apparatus  in  which  ether  may  be  administered  by  insufflation 
through  a  mask.  In  intratracheal  insufflation  anesthesia  the  electric  motor 
which  is  used  to  pump  in  the  air  should  always  be  supplemented  by  a  hand 
or  foot  bellows  to  be  used  in  an  emergency  if  the  motor  breaks  down.  This 
bellows  as  well  as  the  whole  apparatus  should  be  thoroughly  tested  before 
giving  the  anesthesia.  The  pump  should  be  connected  with  an  air  filter 
and  a  manometer,  as  well  as  with  a  safety  valve  of  ample  size,  which  releases 
at  a  pressure  of  about  25  mm.  of  mercury.  In  the  early  stages  of  develop- 
ment of  intratracheal  anesthesia  the  lung  tissue  was  occasionally  ruptured 
because  of  the  absence  of  a  safety  valve.  The  intratracheal  tubes  are  pref- 
erably of  woven  silk  rather  than  rubber,  though  a  rubber  tube  of  the  same 
consistency  as  that  used  in  a  soft  rubber  catheter  is  satisfactory.  The  sizes 
vary  from  22  to  24  French  according  to  the  size  of  the  larynx  and  the  tubes 
should  be  marked  at  two  points,  one  about  12  c.c.  from  the  tip,  which  indi- 
cates the  distance  of  the  glottis  from  the  teeth,  and  the  other  at  26  c.c.  from 
the  tip,  which  indicates  the  distance  from  the  bifurcation  of  the  trachea  to 
the  teeth.  The  tube  should  be  of  such  a  size  as  to  fill  about  half  the  lumen 
of  the  trachea  so  air  can  readily  escape  around  it.  If  too  small  the  returning 
air  escapes  too  ciuickly,  while  if  too  large  excessive  pressure  is  made  in  the 
lung  and  the  interchange  of  air  is  interfered  with.  After  sterilization  the 
tube  is  chilled  with  ice  before  introduction.  It  is  best  introduced  by  the 
direct  laryngoscope,  according  to  the  teclinic  of  Jackson,  the  patient  hav- 
ing been  previously  etherized  in  the  ordinary  manner.  The  tube  is  inserted 
after  the  patient  is  under  full  surgical  anesthesia.  After  the  tube  has  been 
inserted  and  protected  from  the  teeth  by  a  wedge  or  a  clamp  of  some  de- 
vice and  after  the  pumping  apparatus  has  been  connected,  the  epigastrium 
should  be  carefully  noticed  to  see  if  there  is  any  swelling  of  the  stomach  as 
the  tube  may  have  been  inserted  into  the  esophagus  instead  of  into  the 
trachea.  This  mistake  has  happened,  particularly  if  the  tube  is  inserted  by 
the  sense  of  touch,  as  is  the  practice  with  some  operators,  instead  of  through 
the  direct  laryngoscope  of  Jackson. 

One  of  the  chief  disadvantages  of  intratracheal  anesthesia  or  any  form 
of  differential  pressure  is  the  obstruction  to  the  circulation  in  the  lung.  In 
normal  respiration  the  obstruction  to  the  circulation  of  the  blood  in  the  lung 
capillaries  is  greater  after  deep  than  after  shallow  inspirations,  so  that  with 


434  OPERATIVE    SURGERY 

the  continuous  expansion  of  the  lung  by  any  form  of  intratracheal  insuffla- 
tion or  ditferential  pressure  the  circulation  of  the  lung  becomes  greatly  im- 
paired and  this  may  account  for  some  of  the  deaths  that  have  occurred  after 
long  operations  upon  the  lungs  under  ditferential  pressure.  It  is  best 
to  permit  the  lungs  to  collapse  about  once  every  minute  or  even  oftener, 
except  at  some  critical  stage  of  the  operation  when  it  is  necessary  to  have  a 
continuous  expansion  for  a  longer  time.  Just  before  closing  the  wound  and 
after  the  last  stitch  has  been  inserted  but  before  it  is  tied,  a  forceps  is  intro- 
duced into  the  pleural  cavity  and  opened  so  as  to  spread  the  wound  slightly, 
while  the  pressure  within  the  lung  is  raised  sufficiently  to  cause  it  to  fill  out 
the  pleural  cavity.  Air  left  after  surgical  operations  seems  to  predispose  to 
infection,  and  drainage  in  these  cases  is  always  undesirable. 

If,  however,  the  pleura  is  accidently  opened  while  operating  upon  the 
ribs  either  plugging  the  opening  quickly  so  as  to  stabilize  the  air  that  has 
already  entered,  or,  if  the  wound  is  a  large  one,  grasping  the  collapsed  lung 
firmly  with  gauze  or  a  soft  forceps  and  holding  it  steady  will  usually  serve 
to  tide  over  the  crisis. 

In  removing  sections  of  the  chest  Avail  for  tumors  the  same  general  pre- 
cautions should  be  exercised  as  in  operating  for  malignant  diseases  elsewhere. 
An  effort  should  be  made  to  remove  the  tumor  in  one  mass.  The  general 
anatomy  of  the  chest  wall  must  be  borne  in  mind.  A  knowledge  of  the  loca- 
tion of  the  intercostal  and  the  internal  mammary  arteries  is  important.  As 
little  blood  must  be  lost  as  possible  and  this  can  best  be  accomplished  by 
clamping  the  vessels  as  they  are  divided  and  by  separating  the  intercostal 
vessels  from  the  lower  border  of  the  rib  and  doubly  ligating  them  before 
they  are  divided.  Provision  must  be  made  for  closure  of  the  pleural  cavity 
after  removal  of  the  tumor,  if  the  defect  is  so  large  as  to  prevent  approxima- 
tion of  the  pleura.  A  large  flap  with  an  ample  base  and  containing  as  much 
subcutaneous  tissue  as  possible  is  turned  into  the  defect.  The  flap  should 
be  outlined,  dissected  up,  and  be  ready  to  be  placed  over  the  defect,  being 
protected  by  moist  gauze,  before  the  tumor  is  excised.  In  this  way  embar- 
rassment from  the  exposure  of  the  open  pleura  will  be  as  short  as  possible. 
If  an  intratracheal  apparatus  is  unavailable,  or  if  anything  goes  wrong  with 
it,  the  opening  should  be  quickly  filled  with  quantities  of  gauze  wrung  out 
of  salt  solution,  the  tumor  rapidly  removed,  and  the  flap  which  has  previ- 
ously been  formed  is  sutured  in  position,  except  at  its  lower  margin,  before 
removing  the  gauze.  Interrupted  sutures  are  inserted  into  the  lower  portion 
of  the  wound  between  the  flap  and  the  chest  wall  but  not  tied.  The  gauze  is 
then  quickly  removed  and  the  sutures  are  tied.  The  sutures  of  the  flap  of  the 
chest  should  be  interrupted  silkworm-gut  and  should  be  placed  close  together, 
but  tied  not  too  tightly.  The  edges  of  the  wound  may  be  covered  with  strips 
of  iodoform  gauze  that  have  been  soaked  in  compound  tincture  of  benzoin. 
An  abundant  dressing  is  applied  over  the  whole  wound. 

Aside  from  tumors  such  as  carcinomas  which  will  demand  the  excision 
not  only  of  the  rib  but  its  periosteum  and  surrounding  tissue,  there  are  two 


THE    THORAX  435 

indications  for  operation  in  wliicli  the  periosteum  should  be  removed  along 
Avith  the  rib  or  its  cartilage.  Occasionally  in  a  rigid  chest  wall  where  the 
chest  is  barrel  shaped  and  the  ribs  are  fixed,  particularly  in  certain  types 
of  asthma,  it  may  become  necessary  to  mobilize  the  ribs  by  excising  parts 
of  the  costal  cartilage.  This  is  done  by  removing  about  one  and  one-half 
inches  of  the  costal  cartilage  of  the  second,  third,  fourth  and  fifth  ribs.  In 
some  cases  operation  on  one  side  alone  may  be  all  that  is  necessary,  but  usu- 
ally a  bilateral  operation  is  more  effective.  It  will  probably  l)e  safer  to 
operate  upon  the  two  sides  at  different  times.  These  cartilages  may  be  re- 
moved through  a  single  long  vertical  incision  Avliich  exposes  all  of  the  carti- 
lage, or  by  multiple  incisions  over  each  cartilage.  Sometimes  a  portion  of 
the  bony  rib  is  included  along  with  the  cartilage.  It  is  doubtless  better  to 
use  a  single  incision  which  begins  just  below  the  clavicle  and  goes  down- 
Avard  about  three-fourths  of  an  inch  from  the  sternum.  Care  should  be 
taken  not  to  wound  the  internal  mammary  artery.  Each  cartilage  is  cut 
close  to  the  sternum  and  lifted  upward  along  Avith  its  perichondrium  and  dis- 
sected outward  toward  the  rib.  After  the  cartilages  have  been  removed,  the 
intercostal  structures  are  served  together  to  obliterate  the  dead  space  and  les- 
sen the  chances  of  regeneration  of  the  cartilage.  The  operation  can  be  done 
under  local  anesthesia  as  patients  in  Avliich  the  operation  is  indicated  are 
not  good  subjects  for  a  general  anesthesia.  Similarly  in  certain  rib  resections 
to  obliterate  cavities  in  the  pleura  or  when  the  breast  or  pericardium  are  ad- 
herent to  the  chest  wall,  the  periosteum  should  be  removed  along  with  the  rib. 
This  latter  operation  is  known  as  cardiolysis.  It  is  only  applicable  to  that 
type  of  pericarditis  which  is  characterized  by  adhesions  between  the  pericar- 
dium, pleura,  diaphragm  and  mediastinum,  practically  gluing  together  these 
structures  and  the  heart.  Separation  of  these  adhesions  alone  does  but  little 
good  and  is  commonly  folloAved  by  early  recurrence.  In  instances  in  which 
this  operation  is  indicated  the  "work  of  the  heart  is  seriously  interfered  with 
and  the  systolic  contraction  is  followed  by  a  marked  bulging  during  diastole. 
For  cardiolysis  an  incision  is  made  which  is  curved  with  its  convexity 
doAvmvard  on  about  the  level  of  the  fourth  rib  and  is  carried  from  the  left 
border  of  the  sternum  to  the  anterior  axillary  line.  The  incision  is  carried  to 
the  ribs  and  the  skin  and  muscle  on  each  side  of  the  wound  are  dissected  up, 
exposing  the  third,  fourth  and  fifth  ribs  from  the  junction  Avith  their  carti- 
lages for  a  distance  of  about  four  inches.  These  three  ribs  are  resected,  pref- 
erably Avith  their  periosteum  as  otherAvise  they  are  likely  to  regenerate. 
This,  hoAvever,  must  be  carefully  done  over  the  outer  portion  of  the  Avound  as 
there  is  great  risk  of  injuring  the  pleura  at  this  point.  It  may  probably 
be  Aviser  to  remove  the  periosteum  Avith  the  rib  over  the  inner  inch  and  a 
half  where  the  adhesions  are  so  dense  as  to  obliterate  the  pleura  and  in  the 
outer  portion  of  the  wound  Avhere  the  pleura  is  thin  and  likely  to  be  injured 
the  ribs  can  be  removed  subperiosteally.  After  four  inches  of  the  third,  fourth 
and  fifth  ribs  have  been  removed,  the  inner  inch  and  a  half  being  removed  with 
the  periosteum,  the  muscle  is  brought  together  after  hemostasis  has  been  com- 


436  OPERATIVE    SURGERY 

pleted.  The  skin  is  closed  in  the  usual  manner.  Sometimes  the  costal  car- 
tilages are  also  removed  with  the  ribs. 

Typhoid  ribs  occur  after  typhoid  fever  and  as  the  incidence  of  typhoid 
fever  has  been  greatl,v  lessened  by  preventive  medicine  and  vaccination,  this 
disease  is  now  rare.  W.  W.  Keen  brought  this  alTection  into  prominence  in 
his  monograph  on  surgical  diseases  of  typhoid  fever,  in  which  he  reports  sev- 
eral cases.  Operation  for  this  condition  presents  certain  features  that  are 
different  from  operations  for  pure  pyogenic  infections.  The  disease  often 
develops  months  and  even  years  after  an  attack  of  typhoid  and  sometimes, 
unless  a  careful  history  is  taken  or  serum  tests  are  made,  the  occurrence  of 
typhoid  fever  may  be  overlooked.  Typhoid  bacilli  may  remain  in  the  ribs 
in  pure  culture  for  months  or  years  after  the  attack  of  typhoid.  The  disease 
seems  particularly  likely  to  occur  about  the  junction  of  the  rib  and  its  costal 
cartilage,  and  infection  of  the  costal  cartilage  is  obstinate. 

A  thorough  exposure  of  the  diseased  rib  or  ribs  is  made  by  an  incision 
parallel  to  the  ribs  and  the  tissue  on  either  side  is  undermined  and  retracted. 
If  a  fistula  exists  the  incision  is  so  made  as  to  surround  the  fistula  and 
every  care  is  taken  to  prevent  infection  of  the  soft  tissues.  By  previously 
disinfecting  the  superficial  part  of  the  fistula  and  packing  it  with  a  strip 
of  gauze  soaked  in  tincture  of  iodine  just  before  the  operation  contami- 
nation of  the  adjacent  flaps  may  sometimes  be  prevented.  After  the 
flaps  of  skin  and  subcutaneous  tissue  with  the  muscle  over  the  ribs  have 
been  freely  mobilized  and  retracted  the  periosteum  over  the  rib  and  the 
perichondrium  over  the  cartilage  are  incised  and  stripped  up  with  a  peri- 
osteal elevator.  Great  care  must  be  taken  in  doing  this  on  the  under  sur- 
face of  the  rib  because  the  pleura  is  here  very  easily  injured.  In  resect- 
ing a  rib  for  empyema  where  the  pleura  is  thick  and  where  the  purpose 
of  the  operation  is  to  inc4se  the  pleura  there  is  but  little  need  for  care,  but 
with  a  typhoid  rib  and  normal  pleura  the  opening  of  the  pleural  cavity  with 
the  possibility  of  infecting  the  pleura  should  be  carefully  avoided.  By  hug- 
ging the  posterior  surface  of  the  rib  and  exposing  its  edges  and  the  costal 
cartilage  thoroughly  before  attempting  to  strip  the  posterior  layer,  and  then 
working  chiefly  from  above  downward,  injury  to  the  pleura  can  usually  be 
avoided.  It  is  best  fully  to  separate  the  rib  and  divide  it  with  bone  forceps 
at  the  outer  portion  of  the  wound.  It  can  then  be  gently  lifted  and  the 
periosteum  along  with  the  pleura  stripped  off  from  without  inward  as  the 
end  of  the  rib  is  elevated.  AVhen  the  junction  with  the  cartilage  is  reached 
it  may  be  necessary  to  cut  across  the  cartilage  and  remove  the  rest  of  the  dis- 
eased cartilage  with  a  sharp  curet.  Usually  the  lower  ribs  are  affected  and 
their  costal  cartilages  are  fused  together  near  the  sternum.  Not  only  the  rib 
but  the  costal  cartilage  must  be  removed  well  beyond  the  visibly  affected  area, 
else  a  recurrence  is  certain.  As  soon  as  the  rib  has  been  resected  its  bed 
and  the  stump  of  the  rib  should  be  protected  by  moist  gauze  to  avoid  in- 
fection of  the  exposed  end  of  the  rib.  It  is  wise  to  stitch  the  periosteum 
over  the  stump  of  the  rib  before  proceeding  further  with  the  operation.     Af- 


THE    THORAX  437 

ter  removing  a  sufficient  amount  of  the  cartilage  well  into  the  healthy  tissue 
the  exposed  surfaces  of  the  cartilage  together  with  the  periosteum  or  jjeri- 
chondrium  that  has  been  left  are  swa])l)ed  with  gauze  soaked  in  tincture  of 
iodine.  The  wouiul  is  closed  Avith  interrupted  sutures  of  silkworm-gut  but 
provision  should  be  made  for  drainage  by  a  stab  wound  at  a  dependent  por- 
tion of  the  wound  through  which  a  rubber  tube  is  inserted.  The  dressing 
should  be  firm  so  as  to  fix  the  ribs  and  limit  respiration,  otherwise  there 
will  be  considerable  pain  from  the  motion  of  the  unattached  rib.  Usually 
tliere  is  a  congestion  of  the  pleura  because  of  the  proximity  of  the  operation 
and  symptoms  of  localized  pleurisy  may  appear  merely  from  the  trauma  that 
has  been  done  over  the  pleura  and  not  from  any  infection.  Often  the  ribs 
and  cartilage  are  at  least  partially  reproduced  from  the  periosteum  and 
perichondrium  together  with  some  of  the  cambium  layer  which  has  been  left 
after  removal  of  the  rib. 

EMPYEMA 

Removal  of  the  ribs  to  gain  access  to  the  contents  of  the  thorax  is  a  much 
simpler  procedure  than  the  operation  for  typhoid  ribs.  When  resection  of 
a  rib  is  indicated  for  empyema  the  sixth  or  seventh  rib  in  the  midaxillary  line 
or  the  ninth  rib  just  external  to  the  angle  of  the  scapula  is  best  for  an 
unconfined  empyema.  The  operation  should,  as  a  rule,  be  done  under  local 
anesthetic  and  with  care  it  can  be  almost  painless.  Before  beginning  the 
operation  it  is  definitely  ascertained  that  pus  is  present  by  aspirating 
the  pleural  cavity  just  above  or  just  below  the  portion  of  rib  that  the  sur- 
geon intends  to  remove.  After  infiltrating  the  skin  and  subcutaneous  tissues 
with  novocain  solution  an  incision  is  made  down  to  the  periosteum.  Bleeding 
points  are  clamped  and  tied  or  whipped  over  with  catgut  in  a  needle  before 
proceeding  with  the  operation.  After  the  pleural  cavity  has  been  opened 
and  pus  has  contaminated  the  wound  any  manipulation,  such  as  tying  ves- 
sels or  securing  bleeding  points,  is  unwise  as  the  infection  may  thereby  be 
spread.  The  periosteum  is  infiltrated  with  novocain  and  incised  about  the 
middle  of  the  rib  for  a  space  of  two  and  a  half  inches.  Tissues  along  the 
lower  and  upper  border  of  the  rib  should  be  particularly  well  infiltrated.  The 
periosteum  is  stripped  up,  hugging  the  rib  closely,  especially  at  its  lower  bor- 
der where  the  main  intercostal  vessels  lie.  After  exposing  the  bone  above 
and  below,  the  posterior  part  of  the  periosteum  is  infiltrated  with  a  small, 
fine  needle  and  the  periosteum  is  further  separated  from  the  rib.  This  can 
be  readily  done  by  inserting  the  edge  of  a  periosteal  elevator  and  making 
lateral  motions.  The  periosteal  elevator  is  then  placed  beneath  the  rib  which 
is  divided  with,  bone  forceps  at  the  outer  angle  of  the  wound.  The  inner 
portion  is  raised,  the  periosteum  stripped  further  back  if  necessary,  and 
about  two  inches  of  the  rib  are  removed.  The  periosteum  is  incised  longi- 
tudinally in  the  middle  and  pus  allowed  to  escape.  It  should  not  fl.ow  too 
freely  because  this  may  produce  such  sudden  changes  in  the  lung  and  in 


438 


OPERATIVE    SURGERY 


the  circulation  of  tlie  lung  that  the  patient  may  collapse.  No  effort  should 
be  made  to  irrigate  the  cavity  though  any  large  pieces  of  fibrin  that  are 
loose  and  protrude  from  the  wound  should  be  removed.  A  large  rubber 
tube  about  three-fourths  of  an  inch  in  diameter  and  having  two  or  three 
perforations  is  inserted  into  the  wound  for  four  or  five  inches.  The  outer 
portion  of  the  tube  is  split  in  two  pieces  and  each  half  is  perforated  and  a 
long  tape  tied  into  the  perforations.  The  tapes  are  carried  around  the 
body  and  tied  to  each  other.  No  effort  is  made  to  evacuate  all  of  the  pus  im- 
mediately, though  most  of  it  may  be  allowed  to  escape,  stopping  the  flow 
at  intervals  if  coughing  or  other  symptoms  show  that  the  patient  is  being 
too  much  embarrassed  by  the  rapid  flow  of  pus.  Abundant  dry  sterile  dress- 
ings are  applied  and  renewed  every  few  hours  until  the  discharge  decreases. 
The  clean  dressing  should  be  ready  and  should  be  applied  promptly  after 


Fig.    429. — A   method   of   drainage   of   empyema   by    negative   pressure. 

removing  the  soiled  dressing  so  as  to  protect  the  pleural  cavity  from  the  free 
and  unobstructed  ingress  of  air. 

Eesection  of  a  rib  is  not  ahvays  necessary  in  the  treatment  of  empy- 
ema. The  indications  for  the  proper  type  of  operation  must  first  be  ascer- 
tained. In  patients  who  are  desperately  ill  and,  particularly,  those  with 
streptococcic  infection  that  follows  certain  types  of  pneumonia  after  influ- 
enza, resection  of  the  rib  is  distinctly  contraindicated.  Here  the  patient's 
resistance  is  at  the  lowest  ebb,  the  leukocyte  count  is  low,  and  no  more  should 
be  done  than  is  absolutely  necessary.  The  ends  of  the  rib,  too,  are  particularly 
liable  to  become  infected  in  such  cases  and  will  constitute  a  source  of  sepsis. 
Aspiration  or  puncture  with  a  trocar  and  cannula  in  an  intercostal  space 
with  the  insertion  of  a  tube  through  the  cannula  after  the  trocar  has  been 
removed,  can  be  quickly  done  with  but  little  shock  to  the  patient  and  in  this 
type  of  cases  is  undoubtedly  preferable  to  resection  of  the  rib. 

When  the  resistance  is  Ioav,  particularly  in  the  early  streptococcic  infec- 


THE    THORAX 


439 


tious,  operation  slioiild  be  along  as  conservative  lines  as  possible  and  always 
nnder  local  anesthesia.  The  diagnosis  is  definitely  determined  by  aspiration 
and  a  short  incision  is  made  throngh  the  skin  in  the  intercostal  space  through 
which  the  drainage  Avould  be  most  satisfactory  and  usually  in  the  midaxillary 
line.  The  incision  is  made  close  to  the  upper  border  of  the  rib  to  avoid  the 
intercostal  vessels  and  is  only  about  half  an  inch  long.  A  trocar  and  cannula 
are  selected  so  that  a  No.  17  French  catheter  can  be  threaded  through  the 
cannula.  The  trocar  and  cannula  are  thrust  through  the  incision  into  the 
empyema.  The  trocar  is  withdrawn  and  a  soft  rubber  catheter  with  two 
extra  openings  near  its  end  is  threaded  through  the  cannula  until  about 
three  or  four  inches  of  the  catheter  remain  in  the  empyema  cavity.  The  can- 
nula is  gradually  withdrawn  while  threading  more  and  more  of  the  catheter 
into  the  pleural  cavity.  The  amount  of  the  catheter  that  remains  in  the 
pleural  cavity  can  be  readily  determined  by  measuring  the  portion  on  the 
outside  of  the  incision  with  another  catheter.  The  tube  is  so  adjusted  that 
about  six  inches  remain  within  the  pleura.     The  catheter  is  fastened  to  the 


Fig.   430. — A   rubber   tube    for    drainage    of   empyema.      The   wide    flange    permits    the    formation    of    a   valve 

with  a  sheet  of  rubber  dam. 

skin  with  adhesive  straps  and  connected  with  a  rubber  tube  that  carries  the 
drainage  into  a  bottle.  Three  or  four  days  later  negative  pressure  can  be 
arranged  by  connecting  the  drainage  tube  with  a  bottle  from  which  the  air 
has  been  pumped,  or  with  a  collapsible  rubber  bag,  such  as  the  Politzer  bag 
(Fig.  429).  Irrigation  of  an  empyema  cavity,  certainly  in  the  early  stages, 
is  never  advisable. 

There  are  many  methods  of  producing  negative  pressure  in  the  pleural 
cavity,  or  at  least  of  preventing  the  free  entrance  of  air.  The  patients  may 
often  be  permitted  to  walk  around  with  the  drainage  tube  attached  to  a 
bottle  that  is  kept  at  a  partial  vacuum.  While  the  patient  is  in  bed  the 
entrance  of  air  into  the  pleura  may  be  effected  by  connecting  the  drainage 
tube  with  a  tube  of  rubber  dam.  This  is  long,  easily  collapsible,  and  ter- 
minates in  a  bottle  containing  some  antiseptic  solution.  On  expiration  or 
coughing  the  fluid  from  the  pleural  cavity  is  forced  through  this  tube  of  rub- 
ber dam,  but  on  inspiration  the  tube  collapses  and  prevents  ingress  of  air. 
This  method,  which  has  been  suggested  by  Joseph  Ransohoff,  of  Cincinnati,  is 
simple  and  may  be  all  that  is  required.  A  valve  can  be  arranged  over  the  exit  of 
the  tube  if  there  is  a  shoulder  to  the  tube.     A  rubber  tube  that  resembles  a 


440 


OPERATIVE    SURGERY 


spool,  having  a  wide  outer  flange  and  a  narrow  or  no  inner  flange  is  used  (Fig. 
430).  After  insertion  of  tliis  tube  a  little  curtain  of  rubber  dam  is  fastened 
over  the  upper  margin  of  the  tube,  and  will  act  as  a  valve,  permitting 
the  outflow  of  drainage  without  the  entrance  of  air.  This  valve,  however, 
is  likely  to  become  displaced  though  such  a  tube  has  distinct  advantages 
in  enabling  the  drainage  through  the  thoracic  wall  around  the  tube  to  be  air 


Fig.     431. — Operation    of    Estlander    for    chronic    empyema.      A    flap    has    been    turned    uji,     the    ribs    are 
resected   and  the   cavity   of   the   empyema   is   exposed. 


tight.  The  valve  construction  can  be  omitted  and  the  opening  of  the  flanged 
tube  connected  with  another  rubber  tube  and  negative  pressure  can  be  pro- 
vided for  by  some  of  the  methods  that  have  been  described. 

Any  tube  used  for  the  drainage  of  empyema  in  the  intercostal  space  should 
be  either  very  stout  elastic  tube  or  a  rigid  rubber  or  metal  tube,  for  the  ribs 
may  compress  and  occlude  it. 

In  an  old  empyema  where  for  some  reason  drainage  has  been  inefficient  and 


THE    THORAX 


441 


the  lung  has  collapsed,  a  space  is  left  which  is  difficult  of  closure.  Two  prin- 
ciples arc  folloAved  in  operation  for  the  cure  of  this  condition.  In  one  the  ribs 
themselves  are  removed  in  order  to  mobilize  the  chest  wall  and  permit  it 
to  sink  into  the  cavity.  In  the  other  an  attempt  is  made  to  promote  expansion 
of  the  lung-  by  removing  from  it  the  membrane  which  binds  it  down. 

In  mobilizing  the  chest  wall  two  types  of  operations  have  been  employed. 
In  one  operation,  which  is  called  the  method  of  Estlander,  sections  of  several 


\''Ai  \ 


Fig.  432. — The  muscle  flap  is  dissected  and  is  sutured  into  tlie  wound. 

ribs  are  removed  over  the  cavity.  The  upper  portion  of  the  pleural  cavity 
is  more  difficult  to  close  than  the  lower  portion,  as  in  the  lower  portion  the 
diaphragm  frequently  ascends  to  help  the  obliteration.  Care  must  be  taken, 
then,  to  remove  the  ribs  as  high  as  possible.  This  may  be  done  by  a  U-shaped 
incision  or  by  straight  incisions  so  fashioned  that  two  ribs  can  be  removed 
from  each  incision,  which  is  made  in  the  intercostal  space,  the  soft  tissues  be- 
ing retracted  above  or  below.    The  ribs  removed  are  usually  the  second,  third, 


442 


OPERATIVE    SURGERY 


fourth  and  fifth,  though  more  can  be  resected  if  necessary.  The  disadvan- 
tage of  this  operation  is  that  often  in  these  old  cases  the  pleura  and  chest  wall 
are  so  thickened  by  the  inflammation  that  the  chest  wall  will  not  collapse  even 
after  the  ribs  have  been  removed. 

Here  the  operation  of  Schede  may  be  done.  An  incision  begins  at  the 
origin  of  the  major  pectoral  muscle  on  a  level  with  the  axilla  and  is  car- 
ried downAvard  to  a  point  at  the  bottom  of  the  pleural  sac,  which  is  usu- 
ally the  tenth  rib  in  the  posterior  axillary  line.  The  incision  curves  along 
the  lower  part  of  the  chest,  coming  up  behind  the  scapula  at  a  point 
about  the  level  of  the  second  rib  between  the  spine  and  the  scapula.  The 
flap  includes  all  the  tissues  down  to  the  ribs  and  to  the  intercostal  mus- 
cles and  is  dissected  up  freely.    The  ribs  that  are  exposed  are  subperiosteally 


Fig.   433.     Ihe   skin  flap  is   sutured   in  position.     It  is   not  usually   sufficient  to   cover  the   whole   cavity. 

resected  from  their  tubercles  to  the  costal  cartilage,  dividing  the  rib  about 
its  middle  Avith  bone  forceps  and  dissecting  it  from  this' point  outward  and 
forward  until  a  sufficient  amount  of  rib  is  removed.  A  long  incision  is  made 
through  the  periosteum  of  one  of  the  removed  ribs  and  the  pleural  cavity  is  ex- 
plored so  the  exte-nt  to  which  other  ribs  or  tissue  should  be  removed  is  accurately 
ascertained.  After  a  sufficient  amount  of  the  ribs  has  been  resected,  all  of  the  tis- 
sue is  removed  that  seems  to  be  necessary  to  expose  the  cavity  thoroughly,  includ- 
ing the  periosteum,  intercostal  muscles  and  the  thickened  pleura  (Fig.  431).  The 
intercostal  vessels  are  secured  if  possible  before  division  by  clamping  and  are 
ligated  after  the  tissues  have  been  removed.  Every  bleeding  vessel  is  clamped. 
Granulations  are  wiped  away  with  dry  gauze  and  the  flap  which  was  originally 
reflected  is  turned  down  over  the  outer  surface  of  the  collapsed  lung  and 
fastened  in  position  with  sutures  and  pads.  (Fig.  432).  The  flap  is  not 
sufficient  to  cover  the  whole  of  the  wound  but  it  is  tucked  in  to  coA'er  the  lung 


THE    THORAX  443 

surface  of  the  old  enipyenia  cavity  (Fig.  438).  It  is  important  not  to  use  strong 
antiseptics  in  such  an  operation  as  the  great  extent  of  raw  surface  will  make 
absorption  of  some  antiseptics  so  great  as  to  be  toxic. 

Such  an  operation  is  exceedingly  dangerous  on  the  class  of  patients  in 
whom  it  is  indicated  and  it  is  frequently  best  done  in  two  stages,  first  remov- 
ing the  llap  and  excising  one  or  more  of  the  ribs,  and  later  removing  the  chest 
wall  including  the  rest  of  the  ribs,  intercostal  muscles,  periosteum,  and  parietal 
pleura. 

Frequently  the  form  of  flap,  as  suggested  by  Scliede,  is  modified  or  en- 
tirely changed.  S.  Robinson  has  suggested  a  T-shaped  flap  with  the  horizontal 
portion  under  the  axilla  as  this  gives  greater  nutrition  to  the  flaps.  It 
would  be  difficult  to  close  the  opening  by  this  flap  if  the  deepest  part  of  the 
cavity  is  at  the  upper  portion  of  the  iDleura.  Occasionally  muscle,  fat  or  in 
women  the  mammary-  gland  has  been  transplanted  by  a  flap  to  flll  in  the 
cavity  of  an  obstinate  empyema. 

According  to  the  technie  of  Robinson  the  muscles  over  the  chest  may  be 
dissected  free  from  the  skin  and  implanted  as  a  flap  into  the  empyema  cavity. 
Carl  Beck  utilizes  skin  flaps  which  are  held  in  position  by  tampon,  no  stitches 
being  used.    The  denuded  surface  is  inclined  to  heal  rapidly. 

The  operation  of  Fowler  embodies  the  principle  of  removing  the  membrane 
that  binds  down  the  collapsed  lung.  Fowler  and  others  noticed  that  in  most 
cases  of  chronic  empyema,  even  though  the  lung  has  been  collapsed  and  bound 
down  for  years,  it  has  very  considerable  resiliency  if  the  membrane  that 
covers  it  is  removed.  The  pleural  cavity  is  freely  exposed  by  the  resection  of 
three  or  four  ribs  through  an  incision,  which  is  made  to  include  the  ori- 
fice of  the  sinus.  Four  inches  of  the  fifth  and  sixth  ribs  are  removed  and 
the  parietal  pleura  is  widely  opened.  Blunt  dissection  is  begun,  first  in  the 
direction  of  the  diaphragm,  and  the  fibrinous  membrane  is  peeled  oif  from 
the  lung  upward  and  toward  the  midline.  It  is  finally  detached  from  the  lung 
above.  If  the  empyema  has  been  drained  for  more  than  five  months  the  lung 
is  not  likely  to  expand  sufficiently  to  fill  the  cavity.  Ransohoff  in  some  cases 
Avhere  the  peeling  off  of  the  membrane  is  difficult  made  multiple  incisions 
over  the  collapsed  lung  which  are  carried  down  through  this  membrane  and 
criss-crossed  in  such  a  manner  as  to  permit  the  lung  to  expand  without  the 
necessity  of  dissecting  off  the  entire  membrane.  It  is  usually  best  to  combine 
the  principle  of  Estlander  in  multiple  resection  of  the  ribs  with  that  of 
decortication  of  the  lung.  Of  course,  where  the  existence  of  the  empyema  has 
been  so  long  that  the  lung  has  been  hopelessly  collapsed  and  expansion  is 
impossible  decortication  will  be  useless. 

THE  LUNG 

Surgery  of  the  lung  necessitates  approach  to  the  lung  through  the  pleura. 
Where  the  lesion  is  small  this  may  be  done  by  the  same  method  of  re- 
secting the  rib  that  has  been  described  in  empyema.     If,  however,  the  opera- 


444  OPERATIVE    SURGERY 

tion  is  to  be  extensive  or  a  considerable  section  of  the  lung  is  to  be  removed, 
the  exposure  should  be  ample  and  is  probably  best  effected  by  an  intercostal 
incision  through  practically  the  whole  length  of  the  seventh  intercostal  space 
with  forcible  separation  of  the  ribs  by  "rib  spreaders/'  Avhich  are  controlled 
by  poAverful  levers  or  screws.  Or  exposure  may  be  aided  by  resection  of 
a  few  inches  of  the  fifth,  sixth  and  seventh  ribs  posteriorly  near  their  tubercles. 
This  makes  the  mobilization  of  the  chest  wall  less  difficult. 

Abscess  of  the  lung  may  demand  operation.  The  abscess  should  be 
accurately  located  by  ph3^sical  signs,  x-ray  and  an  aspirating  needle.  A.  D. 
Bevan^  practices  incision  in  an  intercostal  space  down  to  the  pleura  under 
local  anesthesia.  This  incision  is  about  three  inches  long  and  is  carried  down 
carefully  through  the  intercostal  muscles  which  are  gently  divided  to  explore 
the  pleura  (Fig.  434).  If  the  pleura  is  normal  in  appearance  the  lung  can  be 
seen  moving  through  it.     The  parietal  pleura  is  pressed  inward  and  the  ab- 


Fig.    434. — Diagram    showing   method    of    injecting    local    anesthetic    for    operation    on    abscess    of    the    lung. 
The  abscess  is  represented  by  the  shaded  area.      (Method  of  A.   D.   Bevan.) 

scess  is  aspirated  for  diagnostic  purposes.  The  needle  should  be  a  very  fine 
one  so  its  withdrawal  will  not  permit  leakage  into  the  pleural  cavity.  The 
wound  is  then  packed  with  iodoform  gauze  which  holds  the  parietal  pleura 
against  the  pleura  of  the  lung  over  a  space  about  two  inches  in  diameter  (Fig. 
435).  In  this  manner  adhesions  are  produced  betAveen  the  parietal  and  the  vis- 
ceral pleura  without  opening  the  pleural  cavity.  Four  or  five  days  later  the 
packing  is  removed  and  the  lung  abscess  is  again  aspirated.  With  a  sharp- 
pointed  electric  cautery  a  tunnel  is  cauterized  through  the  lung  tissue  to 
the  abscess  cavity  alongside  the  aspirating  needle  which  is  carefully  kept 
in  position  (Fig.  436).  As  soon  as  the  cavity  is  entered  a  rubber  drain- 
age tube,  which  is  not  easily  compressed,  such  as  a  soft  rubber  catheter,  is 
inserted  into  the  abscess  cavity  and  fastened  in  position  by  suturing  it  to  the 
edge  of  the  skin  wound  and  also  by  inserting  a  safety  pin. 

C.  A.  Hedblom,-  of  the  Mayo  Clinic,  reports  a  series  of  operations  for  ab- 


^Surgical    Clinics  of   Chicago,  April,   1919,  W.    E.    Satniders   Co.,    Philadelphia,   pp.    349-354. 
^'Med.  Rec,  New  York,  September   13,   1919. 


THE    THORAX 


445 


scess  of  tlic  lung  and  advises  roseetion  of  ajjout  tliree  ribs  under  local  anes- 
thesia with  a  larger  exposure  of  the  abscess  cavity. 

After  operation  the  drainage  may  persist  for  months  or  years  and  the 
fistula  that  is  left  is  difficult  to  close.  Bevan,-^  under  local  anesthesia,  resects 
the  fistulous  tract  left  b}-  prolonged  drainage  of  a  lung  abscess  (Fig.  437). 


Fig.   435. — ^Vn   incision    has   been   made    down   to   the   parietal   pleura,   and   the   wound   is   packed   with   gauze. 

(Bevan.) 


Fig.   436. — Several   days   later    the    abscess   is   opened    with    an    electric    cautery    which    follows    the    aspirating 

needle.      (Bevan. j 


After  resecting  about  three  and  one-half  inches  of  three  or  more  ribs  in  order 
to  give  ample  exposure,  the  fistulous  tract  is  grasped  with  forceps  and  pulled 
down.  The  fistulous  opening  is  split  up  until  the  abscess  cavity  is  found  (Fig. 
438).  The  abscess  cavity  and  the  fistula  are  lined  with  a  tough  membrane 
which  Bevan  dissects  out  under  local  anesthesia,  beginning  with  the  lining 


^Surgical  Clinics  of  Chicago,  December,   1919,  pp.   1319-1324. 


446 


OPERATIVE    SURGERY 


membrane  of  the  abscess  and  dissecting  from  tliat  dowji  to  the  opening  of  the  fis- 
tula, using  the  fistulous  tract  as  a  tractor  (Fig.  438).  A  small  portion  of  the 
adjacent  lung  tissue  is  included  with  the  lining  membrane  of  the  abscess  and 
the  fistula.  The  bronchus  which  opens  into  the  abscess  is  left  without  a 
suture  (Fig.  439).  The  cavity  is  packed  with  iodoform  gauze  and  no  effort  is 
made  to  close  the  incision  except  by  a  few  sutures  in  the  skin  at  the  extremities 
of  the  incision. 

"Wounds  of  the  lung  may  be  sutured,  particularly  when  it  is  necessary  to 
control  bleeding.  Often,  however,  bleeding  can  be  controlled  merely  by  open- 
ing the  pleural  cavity,  which  permits  collapse  of  the  lung  and  so  checks  hemor- 
rhage unless  a  very  large  vessel  is  injured. 


Fig.   437. — The   lines   of  incision   for   closure   of  a   fistula   following   abscess    of   the   lung.      (Bevan.) 


In  injuries  of  the  lower  lobe  of  the  lung  an  intercostal  incision  in  the  sixth 
or  seventh  interspace,  which  extends  the  complete  length  of  the  rib,  gives  ex- 
cellent exposure  when  used  in  connection  with  a  rib  spreader.  This  is  also 
quick  exposure  and  avoids  the  necessity  of  resection,  which  not  only  takes 
more  time,  but  involves  additional  trauma  and  loss  of  blood.  At  the  conclu- 
sion of  the  operation  the  ribs  are  brought  together  by  stout  interrupted  silk 
sutures,  which  are  passed  around  the  ribs  and  tied.  Usually  three  such  su- 
tures at  different  portions  of  the  wound  are  sufficient.  The  upper  lobe 
is  best  exposed  by  a  curved  incision  with  its  convexity  downward,  beginning 
in  front  at  the  second  intercostal  interspace,  going  down  below  the  angle  of 
the  scapula,  and  up  again  parallel  to  the  spine.  In  this  way  the  scapula  can 
be  swung  upward  before  incising  the  third  interspace.  The  rib  spreader  is 
inserted.  The  lung  is  drawn  up  into  the  wound  after  protecting  the  pleura 
as  well  as  possible  by  carefully  packing  it  off  with  moist  gauze.  Bleeding 
points  are  sought  for  and  sutured,  preferably  with  chromic  or  tanned  catgut. 


THE    THORAX 


447 


The  mattress  type  of  suture  or  the  ordinary  single  suture  may  be  used.  The 
sutures  shouUT  be  tied  gently,  else  they  A\ilL  cut  out.  1£  intratracheal  anes- 
thesia is  used  the  pressure  should  be  increased  so  that  the  lung  barely  fills 
the  pleural  cavity  just  before  the  last  sutures  that  render  the  pleura  air  tight 
are  tied. 

In  some  instances,  as  in  localized  tumor  or  bronchiectasis,  excision  of  a 
lobe  of  the  lung  may  be  necessary.  In  excision,  the  lung  is  exposed  prefer- 
ably under  intratracheal  anesthesia  with  a  long  intercostal  incision  and  rib 


Fig.    438. — The    ribs    have   been    resected   and   the   fistulous    tract   is    being   dissected.      (Bevan.) 


spreaders,  or  resection  of  one  or  more  ribs  may  be  done.  After  exposure  the 
diseased  lobe  is  isolated  and  the  pedicle  crushed  as  near  the  hilum  as  possible 
with  a  strong  clamp.  The  lobe  is  cut  aAvay  and  the  vessels  are  tied.  A  stout 
ligature  is  placed  on  the  stump.  A  suture  is  passed  from  the  stump  to  the 
chest  in  order  to  prevent  retraction  of  the  stump  and  to  stabilize  the  medias- 
tinum. This  suture  should  not  be  tight.  A  large  cigarette  drain  is  carried 
down  to  the  stump  of  the  resected  lobe  and  brought  out  through  the  chest  wall. 
S.  Eobinson^  has  done  a  number  of  successful  resections  of  a  lobe  of  the 


^Jour.  Am.  Med.  Assn.,  1917,  Ixix,   355-357. 


448 


OPERATIVE    SURGERY 


lung  and  lie  prefers  doing  this  operation  in  two  or  llirec  stages  and  without 
any  differential  pressure  apparatus  of  any  kind  but  simply  with  the  ordinary 
anesthesia.  He  does  not  use  intratracheal  anesthesia  but  in  bronchiectasis  he 
sometimes  inserts  a  small  tube  through  the  larynx  into  the  trachea  to  remove 
excessive  secretions  by  suction  while  he  is  operating.  The  incision  he  pre- 
fers is  crcscentic   with  its  convexitv  dowuAvard.     It  begins   at   the   fifth   rib 


Fig.   439. — The  dissection   of  the   fistulous   tract   has  been   almost   completed.      This   is   facilitated   by   traction 

on   the  walls  of  the  tract.    (Bevan.) 


two  inches  from  the  spinal  column,  is  carried  across  the  eighth  rib  in  the 
scapular  line  and  then  up  to  the  level  of  the  sixth  rib  in  the  mammary 
line  (Fig.  440).  Skin  and  fat  are  dissected  from  the  muscle  for  about  one 
inch.  The  muscle  fibers  are  divided  transversely  between  clamps.  The 
seventh,  eighth  and  ninth  ribs  are  resected  subperiosteally  from  their  an- 
gles to  the  anterior  axillary  line.  The  intercostal  bundles  are  tied  and  re- 
moved.    The  skin  and  muscle  flap  is  then  replaced  and  the  wound  sutured 


THE    THOKAX 


449 


without  dr;iiii;i,uo.  A  week  later  tlie  seeoiul  sta^e  <tf  the  operation  is  under- 
taken anil  the  flap  is  i-etraeted  after  removing  the  stitches.  New  adhesions 
will  have  foniuHl  with  the  upper  lobe  which  will  anchor  it  in  position.  The 
pleura  is  opiMied  widely  and  the  adhesions  are  separated  first  from  the  dia- 
phragm so  that  a  elamp  may  be  applied  to  the  hilum  of  the  lobe  if  necessary 
(Fig.  441).  The  upper  adhesions  are  then  separated.  If  separation  of  adhe- 
sions is  difficult  it  is  best  to  make  a  third  stage  and  remove  the  lobe  of  the  lung 
a  week  later.  When  this  is  done  a  long  curved  clamp  is  placed  on  the  root  of 
the  lobe  to  be  excised  and  the  lobe  is  cut  away  half  an  inch  from  the  clamp 
(Fig.  442).  The  blood  vessels  and  the  bronchi  are  tied  separately  with  tanned 
or  chromic  catgut  and  a  mass  ligature  of  kangaroo  tendon  or  braided  silk  is 
placed  just  proximal  to  the  clamp  and  tied  firmly  as  the  clamp  is  released. 


Fig.    440. — The    line    of   incision   for   excision   of   a   lobe   of   the   lung.      (S.    Robinson.) 


According  to  Robinson  there  is  always  some  leakage  of  the  bronchial  stump 
and  it  is  not  wise  to  attempt  to  close  the  bronchus  by  burying  it.  The  wound 
is  packed  with  gauze,  no  drainage  tube  being  used,  and  the  gauze  is  not  dis- 
turbed for  four  days  wdien  it  has  become  foul  and  as  much  of  it  is  removed 
as  possible  without  too  much  pain.  Repacking  is  carefully  done  to  prevent 
pocketing.  A  drainage  tube  should  not  substitute  gauze  packing  at  any  time. 
It  will  probably  take  about  four  months  for  obliteration  of  the  cavity. 

The  production  of  artificial  pneumothorax  may  be  necessary  for  the 
control  of  hemorrhage,  or  for  the  cure  of  pulmonary  tuberculosis.  It  may 
be  done  with  a  trocar  and  cannula,  or  with  a  hollow  needle.  In  emergency 
cases  puncture  of  the  pleural  cavity  can  be  performed  Avith  an  ordinary  as- 
pirating needle,  shoving  the  skin  to  one  side  so  that  when  the  needle  is  with- 
drawn the  skin  will  act  as  a  valve  to  prevent  the  entrance  of  air.    In  tuber- 


450 


OPERATIVE    SURGERY 


culosis,  or  where  there  is  no  emergency,  the  operation  should  be  performed 
with  more  care  and  nitrogen  introduced  instead  of  air.  Oxygen  is  rapidly 
absorbed  but  nitrogen  is  absorbed  much  more  slowly.  The  gas  is  warmed 
by  passing  it  through  a  rubber  coil  which  lies  in  a  basin  of  hot  water  be- 
tween the  tank  and  needle.  A  manometer  is  used  and  gas  is  admitted  until  the 
patient  either  gives  signs  of  discomfort  or  until  only  a  slight  pressure 
is  shown.  The  gas  is  not  introduced  until  the  manometer  demonstrates  by 
negative  pressure  and  oscillation  that  the  pleural  cavity  has  been  entered. 
If  the  patient  begins  to  complain  of  difficult  breathing  the  injections  of  gas 


Fig.    441. — The    lung   has   been    exposed   and   the   adhesions    to    tlie    diaphragm    are    being   separated. 

(S.    Robinson.) 


should  be  discontinued  at  once.  The  gas  may  be  injected  every  two  to  five 
days  until  complete  collapse  of  the  lung  is  obtained  and  a  positive  pressure  of 
not  more  than  3'  cm.  is  shown  on  the  manometer.  This  method  is  more  com- 
fortable and  avoids  the  dangers  that  would  occur  if  complete  collapse  of  the 
lung  is  attempted  at  one  sitting. 

In  producing  an  artificial  pneumothorax  for  the  cure  of  tuberculosis  sev- 
eral points  should  be  emphasized.  The  amount  of  nitrogen  introduced  at 
each  sitting  varies  from  200  to  400  c.c.     Some  patients  may  stand  more  than 


THE    THORAX 


451 


others.  The  anterior  or  posterior  axillary  line  and  the  ninth  intercostal 
interspace  are  usually  chosen.  If  on  account  of  adhesions  or  for  other  reason 
this  region  is  not  satisfactory  the  third  interspace  near  the  anterior  axillary 
fold  is  selected.  It  is  best  to  infiltrate  the  tissues  with  novocaine  through  a  fine 
needle  in  order  to  make  the  procedure  as  painless  as  possible,  then  a  larger 
needle  can  be  used  for  the  introduction  of  the  gas,  pulling  the  skin  either  up  or 
down  before  inserting  it  so  that  it  will  have  the  effect  of  a  valve  and  cover  the 
puncture  of  the  needle  and  prevent  the  escape  of  the  gas.  After  the  needle  has 
penetrated  the  pleural  cavity  if  it  is  introduced  carefully  and  the  manometer 
watched  the  lung  will  not  be  injured.     After  complete  collapse  of  the  lung 


Fig.   442. — The   lobe   of   the   lung  is   excised   after   clamping   the   pedicle.      (Robinson.) 


has  been  procured  over  a  series  of  injections  given  every  two  days  no  further 
treatment  need  be  given  for  a  month  or  longer.  The  patient  should  rest  in  bed 
for  a  day  after  the  injection  and  if  there  is  any  embarrassment  of  respiration 
the  injection  should  be  either  discontinued  or  at  least  not  repeated.  The  lung 
should  be  kept  collapsed  from  two  to  three  years  except  in  cases  with  large  cav- 
ities where  the  collapse  should  be  maintained  indefinitely^ 

In  mediastinal  tumors  an  incision  is  made  from  the  sternoclavicular  ar- 
ticulation downward  to  about  the  level  of  the  third  rib  and  then  outward  in 


452  OPERATIVE    SURGERY 

the  fourth  intercostal  space  either  to  the  right  or  left  as  may  be  indicated. 
The  tissues  are  divided  down  to  the  infrahyoid  muscles  and  the  sternum,  the 
index  finger  is  introduced  into  the  notch  above  the  sternum  and  gradually 
carried  down  the  posterior  surface  of  the  sternum,  hugging  the  bone  as  close 
as  possible.  The  pleura  is  exposed  in  the  third  interspace  after  separation  of 
the  major  pectoral  and  intercostal  muscles  and  the  internal  mammary  ves- 
sels are  tied  and  divided.  The  index  finger  of  the  left  hand  is  inserted  through 
the  third  interspace  and  pushed  upward  close  to  the  sternum  until  it  meets 
the  index  finger  of  the  right  hand.  In  this  way  the  vessels  of  the  mediastinum 
are  shoved  out  of  the  Avay  and  the  sternum  can  l)e  divided  longitudinally  Avith 
forceps.  The  raw  surfaces  are  covered  with  gauze  and  forcibly  retracted. 
The  tumor  is  dealt  with  and  the  tissues  are  replaced  in  position  and  held  by 
stout  sutures  passed  around  the  sternum  or  through  drill  holes  along  its  edges. 
If  drill  holes  are  made  care  is  taken  to  protect  the  tissues  beneath  from  the 
drill  point  as  it  penetrates  the  sternum. 

THE  PERICARDIUM  AND  HEART 

The  pericardium  occasionally,  from  trauma  or  disease,  requires  aspiration 
or  incision.  In  pericarditis  the  effusion  may  be  so  marked  as  to  interfere  with 
the  action  of  the  heart,  and  unless  the  pressure  is  relieved  the  patient  will  die. 
The  pericardium  may  be  aspirated  through  an  intercostal  space  near  the 
lower  part  of  the  sternum  without  injuring  the  heart ;  though  there  is  always 
the  possibility  of  puncturing  the  pleura,  even  in  the  fifth  interspace  on  the 
left  side,  because  of  the  rather  irregular  limits  of  the  pleura.  The  suggestion  that 
the  sternum  be  trephined  in  order  to  avoid  the  pleura  is  hardly  practical  as 
aspiration  with  a  fine  needle  will  probably  not  harm  the  pleura,  unless  there  is 
marked  sepsis  and  in  such  instances  aspiration  should  be  for  diagnostic  pur- 
poses only  and  should  be  followed  immediately  by  incision  and  drainage.  The  in- 
ternal mammary  artery  must  be  borne  in  mind,  as  it  lies  about  one-half  an  inch 
from  the  external  border  of  the  sternum.  The  spot  usually  utilized  for  aspiration 
is  the  fifth  left  intercostal  space  about  three-fourths  of  an  inch  from  the  ster- 
num. The  needle  is  passed  backward  and  to  the  right  and,  if  used  for  cura- 
tive purposes,  is  connected  with  a  bottle  in  which  there  is  negative  pressure, 
but  for  diagnostic  purposes  a  syringe  is  all  that  is  necessary.  A  small  trocar 
and  cannula  are  more  satisfactory  than  the  ordinary  aspirating  needle,  par- 
ticularly if  the  effusion  is  not  septic  and  if  it  is  merely  intended  to  draw  off 
the  fluid  and  relieve  the  mechanical  pressure. 

If  the  pericardium  is  to  be  opened,  about  an  inch  of  the  cartilage  of  the 
left  fifth  rib,  together  with  a  small  portion  of  the  adjoining  sternum  is  removed 
with  bone  forceps.  The  internal  mammary  had  best  be  tied  at  the  upper  and 
lower  border  of  the  incision.  After  dividing  the  triangularis  sterni  muscle 
the  pleura  is  identified  if  possible  and  gently  pushed  outward.  If  this  cannot 
be  done  and  if  the  pleura  is  opened  the  incision  into  the  pleura  should  be  closed 
by  sutures.    The  pericardium  is  transfixed  with  a  tenaculum  or  with  a  suture 


THE    THORAX  453 

and  incised  after  protecting  the  tissues  in  the  neighborhood  from  the  fluid 
by  gauze  packing.  A  soft  rubber  tube,  or  a  tube  of  rubber  dam,  is  carried 
to  the  posterior  part  of  the  pericardial  cavity  and  fixed  in  position  by 
a  suture  in  tlu^  edge  of  the  pericardium  which  transfixes  the  tube.  The  rest  of 
the  wound,  ])articular]y  over  the  pleura,  should  be  packed  with  a  gauze  tam- 
pon to  protect  it  from  absorption  of  the  septic  fluid  from  the  pericardium. 

THE  HEART 

Surgery  of  the  heart  consists  in  repairing  wounds.  While  experimentally 
some  work  has  been  done  on  the  valves  of  the  heart  it  has  not  so  far 
been  sufficiently  promising  to  be  even  suggestive  of  clinical  application.  Ex- 
posure of  the  heart  depends  to  some  extent  upon  the  location  and  the  char- 
acter of  the  wound.  The  resection  of  two  to  four  ribs  and  costal  cartilages 
over  the  heart,  or  the  formation  of  a  hinged  flap  consisting  of  the  skin,  ribs, 
muscle  and  periosteum  and  sometimes  including  a  portion  of  the  sternum,  may 
be  used.  Robinson  suggests  as  a  satisfactory  method  of  exposure  of  the 
heart  an  intercostal  incision  and  the  use  of  rib  spreaders.  If  the  ribs  are 
resected  subperiosteally  they  will  regenerate  and  it  is  usually  unnecessary  to 
divide  the  sternum.  A  hinged  flap  with  the  hinge  outward  and  including  the 
skin,  ribs  and  the  periosteum  of  three  of  the  ribs  usually  meets  the  indication. 
The  suggestion  of  Godlee^  that  the  skin  be  reflected  in  one  flap  and  the  mus- 
cles, ribs  and  periosteum  in  another  may  afford  a  more  satisfactory  exposure. 
A  flap  of  horseshoe  or  rectangular  shape  Avith  the  base  external  three  inches 
in  width  and  extending  to  about  half  across  the  sternum  is  outlined. 
The  costal  cartilages  and  the  inner  portion  of  the  fourth,  fifth  and  sixth 
ribs  are  included  in  the  flap.  The  cartilage  is  separated  close  to  the  sternum, 
separating  first  the  fourth,  then  the  fifth  and  sixth.  The  ribs  themselves  are 
cut  with  bone  forceps  about  three  or  four  inches  from  the  sternum.  After  li- 
gating  the  internal  mammary  artery  at  the  upper  and  lower  margins  of  the 
flap  the  flap  is  raised  and  retracted  outward  forcibly.  Care  should  be  taken 
to  avoid  injuring  the  pleura  if  possible,  but  if  it  is  injured  the  wound  may 
be  sutured  along  with  a  margin  of  the  lung  and  the  pleural  wound  covered  with 
moist  gauze  held  flrmly  in  position  until  the  completion  of  the  operation.  A 
pneumothorax  lessens  the  force  of  the  heart  and  may  make  the  suturing  of  the 
heart  easier.  The  pericardium  which  is  exposed  is  incised  vertically  and 
lateral  incisions  may  be  made  if  necessary  to  obtain  more  room.  The  wound 
is  sought  for  and  care  is  taken  to  prevent  aspiration  of  air  into  the  heart.  It 
may  be  necessary  to  resort  to  different  methods  in  order  to  insert  the  sutures. 
Sometimes  the  heart  can  be  gently  grasped  with  the  hand  of  the  surgeon  while 
the  suture  is  being  placed.  If  the  wound  is  large  and  has  been  temporarily 
occluded  by  a  blood  clot,  sutures  can  be  inserted  when  the  blood  clot  is  in 
position,  but  if  the  blood  clot  is  dislodged  and  hemorrhage  occurs  the  wound 
is   temporarily    closed    by    plugging    it    with    the    finger    or    thumb    with    one 


^Oxford   Surgery,   iv,    174. 


454 


OPERATIVE    SURGERY 


hand  while  the  sutures  are  being  inserted  with  the  other  hand.  Tanned  cat- 
gut may  be  used  for  the  suture  material,  though  on  account  of  the  constant 
motion  of  the  heart  and  the  tendency  to  loosening  of  the  knot,  linen  or  silk 
is  preferable.  The  sutures  should  always  be  interrupted  and  introduced  with 
a  full  curved  needle.  While  the  sutures  are  being  placed  the  heart  is  steadied 
either  by  the  left  hand  of  the  surgeon  or  by  silk  tractor  sutures  that  are  in- 
serted near  the  apex  of  the  heart.  Care  must  be  taken  to  avoid  injury  to 
the  corouar}^  arteries  or  their  branches.  It  must  be  remembered  that  the  heart 
can  be  completely  stopped  if  necessary  for  a  period  of  one  minute  or  slightly 
longer  if  the  hemorrhage  is  of  such  a  character  as  to  demand  this.     Pressure 


Fig.   443. — Lines  of  incision  for   the   operation   of  Trendelenburg   for  pulmonary   embolism. 


around  the  base  of  the  heart  with  a  rubber  tube,  or  a  soft  clamp  on  the  supe- 
rior and  the  inferior  vena  cava  at  the  base  of  the  heart  will,  of  course,  render  the 
heart  bloodless  but  they  are  dangerous  procedures  and  should  not  be  resorted 
to  unless  it  is  apparent  that  the  wound  cannot  be  sutured  in  any  other  way. 
If  the  pleura  has  been  injured  and  has  not  been  sutured  it  should  be  carefully 
closed  by  sutures.  It  is  best  to  drain  the  pericardium  by  rubber  tissue  or  a 
small  soft  rubber  tube,  which  is  fixed  to  the  lower  angle  of  the  incision  in 
the  pericardium  by  a  suture.  The  pericardium  is  united  with  a  continuous 
suture  of  silk,  linen  or  tanned  catgut.  The  flap  of  ribs,  muscles  and  skin  is 
replaced,  drainage  being  brought  out  at  the  lower  border  of  the  wound.  The 
sutures  into  the  periosteum,  connective  tissue  and  muscle  will  hold  the  deep 


TPIE    THORAX 


455 


portion  of  tlie  (lap  in  position.  The  skin  is  sutured  accurately  in  the  usual 
way.  Too  much  pressure  must  not  be  placed  over  the  flap,  as  it  may  cause  it 
to  press  too  greatly  upon  the  heart. 

After  the  history  of  an  injury  with  marked  effusion  into  the  |)erieardium 
which  necessitates  operation  the  pericardium  should  be  opened  even  though 
there  is  no  visible  sign  of  injury.  Death  has  resulted  from  rupture  of  the 
heart  muscle  due  to  the  trauma  inflicted  by  a  bullet  upon  the  pericardium  which 
was  not  itself  penetrated. 

Trendelenburg  has  devised  an  operation  for  pulmonary  embolism,  in 
which  the  exposure  is  somewhat  similar  to  the  exposure  for  suturing  the  heart. 
He  makes  a  horizontal  incision  about  four  inches  long  on  the  second  rib  on  the 
left  side,  beginning  at  the  border  of  the  sternum  and  dividing  the  skin,  fascia 
and  pectoral  muscle.    At  the  inner  extremity  of  this  incision  there  is  a  perpen- 


/ 


Fig.  444. — Incision  into  the  pulmonary  artery,  which  is  held  open  by  self-retaining  forceps.     (Trendelenburg.) 


dicular  cut  which  begins  just  below  the  left  sternoclavicular  articulation  and 
goes  downward  to  the  loAver  border  of  the  cartilage  of  the  third  rib  one  inch 
from  the  border  of  the  sternum  (Fig.  443).  In  this  way  the  internal  mam- 
mary artery  is  avoided.  Two  triangular  flaps  are  made  by  this  T-shaped  in- 
cision and  they  are  reflected.  The  second  rib  is  isolated  for  four  and  one- 
half  inches  and  divided  at  the  outer  end  of  the  incision.  The  rib  is  raised 
subperiosteally  and  twisted  from  its  cartilage,  which  is  also  removed.  The 
third  cartilage  is  divided  to  give  more  space  and  if  the  pleura  has  not  been 
opened  by  this  time  a  T-shaped  incision  is  made  which  corresponds  to  the 
original  incision.  The  lung  is  permitted  to  collapse  and  the  pericardium  is 
exposed.  The  phrenic  nerve  and  the  pulmonary  vessels  are  easily  seen  and 
the  pericardium  is  divided  just  internal  to  the  phrenic  nerve.  The  wound 
is  extended  upward  and  backward  until  the  entire  upper  half  of  the  peri- 
cardium is  incised.  The  lower  part  of  the  pericardium  is  not  cut  and  the 
heart  is  left  in  its  normal  position.     All  this  is  supposed  to  be  done  in  five 


456 


OPERATIVE    SURGERY 


Fig.   445. — The   circulation   at   the   base   of   the   heart   has   been    temporarily    controlled    with    a    rubber    tube. 
Forceps  are   withdrawing  the   embolism  from  the  pulmonary  artery.      (Trendelenburg.) 


miimtes.  Intratracheal  insufflation  anesthesia  should  be  used  if  possible, 
though  it  is  not  necessary.  With  the  instruments  that  have  been  devised  by 
Trendelenburg  a  rubber  tube  is  quickly  drawn  through  the  transverse  sinus 
of  the  pericardium  surrounding  the  ascending  aorta,  and  the  pulmonary  ar- 
tery is  pulled  up  for  compression  immediately  before  the  surgeon  incises  the 
pulmonary  artery.     A  thin  layer  of  fat  with  the  visceral  layer  of  pericar- 


THE    THORAX 


457 


Fig.   446.— The   incision   in   the   pulmonary  artery   is   closed  by   a  clamp   and   sutured   with   fine   silk. 

(Trendelenburg.) 

diiim  is  torn  through  and  an  incision  half  an  inch  long  is  made  in  the  pul- 
monary artery  (Fig.  444).  With  a  special  curved  blunt  forceps  introduced 
into  the  main  trunk  of  the  pulmonary  artery  and  then  into  its  branches  the 
embolus  or  thrombus  is  grasped  and  extracted  (Fig.  445).  This  must  be  done 
in  forty-five  seconds,  because  interruption  of  the  general  circulation  is  not 
tolerated  longer.  The  margins  of  the  wound  in  the  pulmonary  artery  are 
lifted  by  special  forceps  and  closed  by  a  clamp  after  which  the  elastic  com- 
pression around  the  aorta  and  pulmonary  artery  is  relaxed  (Fig.  446).     The 


458  OPERATIVE    SURGERY 

circulatiou  is  thus  reestablished  and  the  heart  beats  violently  if  it  has  not 
altogether  ceased  to  beat.  The  constriction  can  be  tightened  again  and  an- 
other search  made  for  the  embolus,  though  the  circulation  must  not  be  cut  off 
for  more  than  forty-five  seconds  at  any  one  time.  The  wound  in  the  pulmo- 
nary artery  is  closed  Avhile  the  clamp  partly,  but  not  completely,  constricts  the 
pulmonary  artery.  The  Avound  is  sutured  v\ath  fine  silk.  The  pericardium 
and  chest  wounds  are  closed  in  the  usual  way.  Twelve  cases  have  been  oper- 
ated upon  in  Trendelenburg's  clinic  without  a  permanent  recovery,  though 
one  lived  for  four  days  and  another  died  from  pneumonia  on  the  fifth  day 
after  operation.  In  view  of  the  gravity  of  the  situation,  however,  it  may  be 
possible  that  under  ideal  conditions  such  an  operation  can  be  undertaken 
successfully. 

PARALYSIS  OF  MUSCLES  OF  THE  THORAX 

Occasionally  in  order  to  secure  rest  of  the  lung  and  to  paralyze  the  half 
of  the  diaphragm  under  a  diseased  lung,  the  phrenic  nerve  is  cut.  In  persist- 
ent hiccough,  which  it  can  be  demonstrated  occurs  only  on  one  side,  the 
phrenic  nerve  is  sometimes  exiDosed  and  infiltrated  Avith  60  per  cent  alcohol. 
The  phrenic  nerve  is  also  supposed  to  carry  some  sensory  fibers  Avhich  regis- 
ter pain  in  the  shoulder  in  some  cases  of  chronic  tuberculosis.  Injection  of 
60  per  cent  alcohol  is  more  desirable  than  a  complete  division  of  the  nerve,  as 
it  may  not  put  the  nerve  completely  out  of  commission  and  yet,  wall  interfere  with 
its  function  sufficiently  long  to  give  rest.  To  expose  the  phrenic  nerve  the 
head  is  turned  to  the  opposite  side  and  an  incision  made  along  the  posterior 
border  of  the  sternomastoid  muscle.  After  dividing  or  retracting  the  exter- 
nal jugular  vein  the  sternomastoid  is  retracted  inward  and  the  phrenic  nerve 
is  found  coursing  downward  and  forward  on  the  scalenus  anticus  and  forming 
an  acute  angle  with  a  portion  of  the  brachial  plexus. 

Paralysis  of  the  serratus  magnus  may  occur  after  operations  in  the  axilla 
in  which  the  posterior  thoracic  nerve  is  injured.  After  operations  on  the  neck 
in  which  the  spinal  accessory  nerve  is  cut  the  trapezius  is  partly  paralyzed. 
It  is  not  often  that  these  two  muscles  are  paralyzed  at  the  same  time  from  sur- 
gical operations,  because  the  nerves  that  supply  them  lie  in  regions  of  the 
body  that  are  not  likely  to  be  involved  by  the  same  disease.  The  modern 
technic  for  operations  for  cancer  of  the  breast  tends  to  avoid  injurj^  to  the 
posterior  thoracic  nerve  and  except  in  malignancy  of  neck  tumors  the  spinal 
accessory  can  usually  be  spared  in  dissection  of  the  neck.  In  paralysis  of 
the  serratus  magnus  the  posterior  border  of  the  scaj^ula  tends  to  flare  upward 
and  may  produce  considerable  disability  and  deformity.  This  can  be  par- 
tially corrected.  A  perpendicular  incision  along  the  vertebral  border  of  the 
scapula  from  its  upper  to  its  lower  angle.  The  trapezius  and  major  rhom- 
boideus  muscles  are  di^dded  and  the  latissimus  dorsi  is  retracted  dowuAvard. 
The  periosteum  is  exposed  along  the  border  of  the  scapula  and  reflected  along 
with  its  attached  muscle  on  the  external  surface  and  likewise  on  the  internal 


THE    THORAX  459 

surface,  and  the  excess  oi"  pcriosleuni  on  the  iiiterjial  surface  of  the  scapula  is 
excised.  The  sixth  and  seventh  ril)s  are  denuded  of  periosteum  about  two 
and  tliree-fourths  inches  from  the  spine,  denuding  the  seventh  rib  one-half 
an  incli  farther  out  than  the  sixth.  Holes  are  drilled  through  the  posterior 
border  of  the  scapula  and  wire  sutures  are  passed  through  these  holes  and 
around  the  sixtli  and  seventh  ribs.  The  wires  are  twisted  and  cut  short  and 
the  periosteum  is  reflected  over  them  as  far  as  possible.  The  inner  portion 
of  the  wound  is  retracted  and  the  long  muscles  of  the  back  are  exposed,  and  a 
long  thick  flap  of  muscle  with  its  pedicle  below  is  dissected  out  and  sutured 
at  the  upper  angle  of  the  scapula  to  the  periosteum  and  supraspinatus  mus- 
cle. Duval,  who  devised  this  operation,  advises  a  plaster  of  Paris  dressing  for 
about  forty-eight  days. 

A  somewhat  better  procedure  consists  in  a  transplantation  of  muscles  if 
this  can  be  done.  Katzenstein  has  suggested  the  transplantation  of  portions 
of  the  trapezius  muscle  and  of  the  pectoralis  major  in  paralysis  of  the  ser- 
ratus.  When  the  trapezius  is  completely  paralyzed  the  upper  margin  of  the 
latissimus  dorsi  is  exposed  and  a  flap  split  off  from  this  muscle  near  its  inser- 
tion into  the  humerus  so  that  the  flap  has  a  posterior  pedicle.  The  free  end  of 
this  is  then  sutured  to  the  posterior  surface  of  the  scapula  so  as  to  take  the 
place  of  the  lower  fibers  of  the  paralyzed  trapezius.  A  flap  can  be  turned 
over  from  the  opposite  healthy  trapezius  and  sutured  to  the  middle  portion  of 
the  posterior  border  of  the  scapula  taking  care  to  preserve  its  nerve  supply 
by  severing  the  outer  end  of  the  flap  along  the  clavicular  insertion.  Finally, 
another  flap  can  be  taken  from  the  middle  of  the  trapezius  with  its  base  toward 
the  spine  and  sutured  to  the  border  of  the  scapula.  In  paralysis  of  the  ser- 
ratus  magnus  or  the  serratus  and  the  trapezius  muscles,  the  spinal  origin  of 
the  rhomboid  muscles  can  be  divided  and  transplanted  to  the  lower  verte- 
brae to  make  them  assist  the  serratus  magnus  muscle.  The  tendon  of  the 
major  pectoral  may  be  divided  at  its  insertion  into  the  humerus  and  sutured 
to  the  axillary  border  of  the  scapula.  In  paralysis  of  the  trapezius  a  free 
transplant  of  fascia  according  to  the  method  of  Eothschild  can  be  done.  Here 
a  strip  of  fascia  lata  about  eight  inches  long  and  two  inches  wide  is  taken 
from  the  thigh  after  exposing  the  posterior  border  of  the  scapula  by  an  incis- 
ion from  its  upper  angle  down  to  the  first  lumbar  vertebra.  One  end  of  the 
strip  of  fascia  is  sutured  to  the  supraspinatus  muscle  and  fascia  over  it  and 
the  other  end  to  the  latissimus  dorsi  and  muscles  near  the  spine.  The  fascial 
transplant  must  be  put  on  tension  before  being  sutured  in  order  to  see  that 
the  scapula  on  the  paralyzed  side  is  pulled  to  the  level  of  the  scapula  on  the 
normal  side  and  that  its  posterior  border  is  parallel  to  the  spine.  To  prevent 
adhesions  between  the  fascia  and  skin  a  small  opening  may  be  made  through 
the  paralyzed  trapezius  near  the  scapula  and  the  lower  portion  of  the  trans- 
plant carried  beneath  the  muscle  to  the  point  where  it  is  sutured  into  the 
structures  around  the  origin  of  the  latissimus  dorsi. 

In  deltoid  paralysis  Dean  Lewis  operates  by  transplanting  muscle  to  over- 
come this  defect.    He  makes  an  incision  from  about  the  middle  of  the  outer 


460  OPERATIVE    SURGERY 

border  of  the  trapezius  to  a  point  at  the  junction  of  the  middle  and  lower 
thirds  of  the  deltoid  muscle.  The  clavicular,  acromial,  and  a  portion  of  the 
spinous  attachment  of  the  trapezius  muscle  are  divided,  the  paralyzed  del- 
toid is  separated  from  the  clavicle  and  spine  of  the  scapula  and  turned  down 
and  the  sheath  of  the  long  head  of  the  biceps  is  incised  and  its  tendon  pli- 
cated so  as  to  bring  the  head  of  the  humerus  into  proper  position.  The  flaps 
from  the  trapezius  muscle  are  now  sutured  to  the  capsule  of  the  shoulder 
joint  where  it  is  attached  to  the  humerus  and  the  deltoid  muscle  which  has 
been  turned  down  is  sutured  over  the  trapezius  as  high  up  as  possible  while 
the  arm  is  abducted.  The  upper  part  of  the  wound  in  the  skin  is  sutured 
transversely  to  the  direction  of  the  incision  so  as  to  make  some  tension  on 
the  tissues  around  the  shoulder  joint.  This  makes  a  T-shaped  scar.  The  arm 
is  immobilized  in  plaster  of  Paris  for  about  four  weeks  at  an  angle  of  about 
100  degrees  and  is  then  gradually  taken  down. 

THE  SCAPULA  AND  CLAVICLE 

Excision  of  the  scapula  may  be  necessary  on  account  of  malignant  disease  or 
from  severe  infection,  which  produces  osteomyelitis.  "When  it  is  done  for  osteo- 
myelitis the  operation  can  be  conducted  subperiosteally  according  to  the  method 
of  Oilier,  by  an  incision  along  the  entire  length  of  the  spine  of  the  scapula 
through  which  the  periosteum  and  the  muscles  are  raised  from  the  spine  of 
the  scapula.  Then  another  incision  is  made  along  the  posterior  border  of  the 
scapula  and  the  periosteum  and  its  attached  muscles  are  raised.  The  poste- 
rior border  of  the  scapula  is  retracted  stronglj^  away  from  the  chest  and  the 
periosteum  of  the  under  surface  of  the  scapula  is  separated  from  the  bone  until 
the  neck  of  the  scapula  is  reached.  The  acromioclavicular  joint  is  divided 
from  below  upward  and  the  capsule  of  the  shoulder  is  cut.  The  base  of 
the  coracoid  process  is  severed  with  bone  forceps  and  the  head  of  the  scapula 
is  left  in  position  if  possible,  dividing  the  neck  of  the  bone  so  as  to  interfere 
as  little  as  possible  with  the  shoulder  joint.  Portions  of  the  scapula  may  be 
excised  by  incisions  placed  according  to  the  indications  of  the  disease.  In 
malignant  disease  of  the  scapula,  however,  the  bone  together  with  much  of 
its  attached  structures  must  be  removed.  Here  the  incision  is  first  made 
from  the  apex  of  the  axilla  down  the  arm  for  about  three  inches  along  the 
inner  and  posterior  border  of  the  coracobrachialis  muscle.  The  coracoid  proc- 
ess is  exposed  by  raising  the  anterior  axillary  fold  and  the  muscles  inserted 
into  this  process  are  divided  close  to  the  bone.  The  axillary  artery  is  fully 
exposed  and  the  subscapular  artery  is  doubly  ligated  and  divided  close  to  the 
axillary  artery.  This  wound  is  protected  with  gauze  and  the  patient  is  turned 
on  the  opposite  side  and  an  incision  made  along  the  Avhole  length  of  the  spine 
of  the  scapula  to  the  point  of  the  acromion  process.  Another  incision  at  a  right 
angle  to  this  runs  along  the  posterior  border  of  the  scapula.  The  skin  flaps 
are  retracted  along  with  the  subcuticular  tissue.  Some  of  the  muscle  that 
arises  from  the  scapula  is  divided,  leaving  as  much  muscle  attached  as  seems 
wise.     The  deltoid  and  trapezius  muscles  are  split  along  the  junction  of  their 


THE    THORAX  461 

scapular  and  clavicular  portions  and  divided  so  as  to  remove  a  suffi- 
cient (luaiilily  of  the  muscle  along  with  the  scapula  to  make  it  reasonably 
certain  that  all  of  J  he  disease  is  included  in  the  removed  tissue.  The  clavicular 
part  of  the  deltoid  muscle  can  be  preserved.  The  tendons  of  muscles  which 
are  inserted  iiito  the  upper  end  of  the  humerus  are  divided  and  the  capsule 
of  the  shoulder  joint  is  opened.  The  long  head  of  the  triceps,  which  is  in 
the  upper  and  outer  part  of  the  wound  under  the  head  of  the  humerus,  is 
isolated  and  severed  carefully  so  as  to  avoid  injuring  the  circumflex  nerve. 
If  the  acromion  process  is  to  be  preserved  it  may  be  divided  with  forceps 
or  a  saw.  If  it  is  near  the  disease  it  should  be  removed  along  with  the  rest 
of  the  scapula.  The  portion  of  the  trapezius  muscle  that  is  to  be  removed  is 
divided,  inserting  the  finger  under  it  Avhile  the  muscle  is  cut  with  scissors 
or  a  knife.  The  omohyoid  muscle,  which  arises  from  the  upper  portions  of 
the  neck  of  the  scapula,  is  detached  and  the  suprascapular  artery  is  divided 
and,  at  the  outer  upper  angle  of  the  scapula,  a  branch  of  the  transverse 
cervical  arter}^  is  cut.  The  rhomboideus  muscle  and  the  serratus  magnus 
are  severed.  The  capsule  of  the  shoulder  joint  is  completely  divided  and 
the  scapula  is  removed.  The  upper  part  of  the  capsule  of  the  shoulder  joint 
may  be  sutured  to  the  clavicle  with  wire  sutures.  The  long  head  of  the 
biceps  may  also  be  sutured  to  the  clavicle  and  if  a  part  of  the  deltoid  muscle 
has  been  preserved  this  may  be  sutured  to  the  rhomboideus  and  to  the 
trapezius. 

Excision  of  the  clavicle  may  also  be  done  for  osteomyelitis  or  for  malig- 
nancy. When  this  bone  is  to  be  removed  because  of  osteomyelitis,  an  incision 
is  made  along  the  subcutaneous  portion  of  the  clavicle,  and  the  periosteum  is 
divided  to  the  bone  and  carefully  separated  with  a  periosteal  elevator,  par- 
ticularly behind  and  below  where  important  structures  are  in  close  contact 
with  the  clavicle.  The  bone  may  be  divided  in  its  middle  with  forceps  or 
a  wire  saw  and  each  end  removed  separately,  or  it  may  be  severed  from  the 
joint  at  the  outer  or  inner  end  and  separated  in  this  manner. 

In  malignant  disease,  however,  a  more  radical  operation  is  necessary. 
An  incision  is  made  along  the  length  of  the  bone  through  the  skin  and  addi- 
tional incisions  at  right  angles  to  the  ends  of  this  long  cut  may  be  necessary 
for  satisfactory  exposure.  After  the  skin  and  subcuticular  tissues  have  been 
dissected  from  the  clavicle  and  its  growth,  the  outer  portion  of  the  sterno- 
mastoid  muscle  is  exposed  and  divided  after  inserting  the  finger  under  the 
muscle  to  protect  the  deep  structures.  The  insertion  of  the  trapezius  mus- 
cle is  similarly  divided  at  the  outer  portion  of  the  clavicle  and  the  major  pec- 
toral and  deltoid  attachments  are  likewise  severed.  The  ligaments  at  the  outer 
end  of  the  clavicle  are  divided,  severing  first  the  ligament  to  the  acromion 
process  and  then  that  to  the  coracoid.  The  acromioclavicular  joint  is  com- 
pletely severed  and  the  outer  end  of  the  clavicle  is  pulled  forward  and  up- 
ward. The  tissues  are  then  dissected  from  the  posterior  portion  of  the  clavicle 
up  to  the  sternoclavicular  joint,  taking  care  to  avoid  injury  to  the  sub- 
clavian vein.  The  wound  is  closed  in  the  usual  manner  and  the  shoulder 
and  arm  are  immobilized  by  an  abundant  dressing. 


CHAPTER  XXI 
OPERATIONS  ON  THE  MAMMARY  GLAND 

The  mammary  gland  is  subject  to  disease  but  the  results  of  operations  upon 
it  are,  as  a  rule,  satisfactory  if  properly  performed  and  at  an  early  stage  of  the 
disease. 

Inflammation  of  the  mammary  gland  that  results  in  suppuration  requires 
incision  and  drainage  as  in  abscesses  elsewhere.  These  incisions  should  be 
made  along  the  periphery  of  the  gland,  radiating  from  the  nipple  to  avoid 
injury  to  the  milk  ducts  that  converge  at  the  nipple.  Large  single  abscesses 
should  be  opened  at  the  most  dependent  portion  of  the  breast  and  abun- 
dant drainage  provided  by  a  single  large  tube  or  by  multiple  tubes.  The 
breast  is  gently  compressed  by  large  dressings,  as  relaxed  tissue  with- 
out the  application  of  moderately  firm  pressure  tends  to  form  pockets. 
In  some  multiple  abscesses  drainage  and  incision  are  ineffectual  and  it  is 
then  necessary  to  excise  the  breast.  This  may  be  done  in  such  a  manner  as  to 
preserve  the  nipple  and  a  flap  of  skin  covering  the  upper  portion  of  the  breast. 
Where  this  operation  is  necessary  multiple  abscesses  have  so  riddled  the  breast 
that  there  is  but  little  gland  tissue  left,  and  the  operation  is  in  the  true  sense  of 
the  word  a  conservative  one.  Here  the  breast  is  approached  from  the  lower  and 
outer  portion,  as  in  the  Warren  operation,  and  is  first  dissected  from  the  pectoral 
muscle  by  an  incision  along  the  inner,  lower  and  outer  quadrants,  protecting 
as  far  as  possible  the  wound  from  the  pus.  This  can  be  done  by  enveloping 
the  breast  with  moist  gauze  or  a  Avet  towel,  taking  care  that  the  pus  from 
the  sinuses  has  been  irrigated  carefully  before  the  incision  is  made.  The 
breast  is  lifted  up  and  the  bleeding  vessels  are  clamped  and  tied.  The  wound  over 
the  pectoral  muscle  is  protected  by  layers  of  moist  gauze  and  the  breast  is  dropped 
back  on  the  moist  gauze.  An  incision  is  then  made  in  the  skin  to  include  if  possi- 
ble the  nipple  and  an  upper  flap  of  skin.  The  skin  covering  the  lower  and  outer 
quadrants  of  the  breast  through  which  there  has  been  gravity  drainage  is  left  at- 
tached to  the  diseased  mammary  gland  and  is  removed  with  the  breast.  The  skin 
flap  is  reflected  to  the  upper  limits  of  the  mammary  gland  including  as  much  of 
the  attached  fat  as  possible.  The  upper  skin  flap  is  retracted  strongly  and  the 
breast  severed  from  its  attachments  near  the  sternum  and  outward  toward  the  ax- 
illa. All  bleeding  points  are  carefully  tied  and  drainage  is  established  by  a  tube  at 
the  outer  portion  of  the  wound,  or,  preferably,  through  a  stab  wound  just 
below  the  outer  portion  of  the  wound.  The  wound  is  closed  with  sutures  of 
interrupted  silkw^orm-gut. 

Operations  for  benign  tumors  of  the  breast  are  planned  according  to 
the  size  and  character  of  the  tumor.     If  there  is  a  reasonable  suspicion  that 

462 


THE    MAMMARY    GLAND  463 

the  tumor  is  malignant,  and  always  in  exploratory  operations  in  which  malig- 
nancy is  expected,  the  incision  should  be  made  directly  over  the  growth 
regardless  of  the  probable  cosmetic  effects  of  the  scar.  As  little  raw  surface  as 
possible  sliould  be  exposed  to  the  chance  of  contact  with  cancer  cells. 
Such  operations  as  the  Warren  operation,  which  turns  up  the  breast  by  an 
incision  along  its  lower  margin  and  approaches  the  tumor  from  below,  may 
expose  the  cells  of  a  malignant  tumor  to  inoculation  over  an  extensive  raAV 
surface.  At  the  same  time  the  incision  is  of  such  a  character  as  to  make  it 
difficult  satisfactorily  to  perform  a  radical  operation  if  the  neoplasm  should 
prove  to  be  definitely  malignant.  Furthermore,  one  of  the  chief  principles 
that  Halsted  and  others  have  demonstrated  in  radical  operations  for  can- 
cer is  violated.  Cancerous  tissue  should  be  removed  in  one  mass,  and  when  the 
breast  has  been  previously  separated  from  the  pectoral  muscle  the  lymphatics 
that  carry  cancer  cells  toward  the  axilla  have  been  divided. 

The  Warren  operation  is  a  modification  of  the  original  incision  sug- 
gested by  T.  Gaillard  Thomas.  In  Warren's  original  communication^  he 
desired  an  incision  quite  similar  to  that  of  Thomas,  which  is  beneath  the  breast. 
Later,-  however,  he  places  the  incision  along  the  outer  hemisphere  to  coincide 
with  the  edges  of  the  breast  and  he  finds  that  it  gives  free  access  to  the 
upper  hemisphere  and  at  the  same  time  to  the  outer  portion  of  the  breast, 
which  are  regions  that  are  more  frequently  the  site  of  tumors  than  the 
inner  quadrants.  The  incision  ma}'^  be  prolonged  upward  toward  the  ax- 
illa in  such  a  way  as  to  throw  the  breast  over  toward  the  sternum  and  ex- 
pose freely  even  the  inner  regions.  Care  is  taken  not  to  divide  the  thoracic 
arteries  though  there  is  sui^cient  nutrition  from  the  internal  mammary  per- 
forating branches.  The  dissection  is  carried  down  to  the  outer  edge  of  the 
major  pectoral  muscle  and  uncovers  the  fascia  which  lines  the  posterior  sur- 
face of  the  mammary  gland.  This  fascia  is  dissected  from  the  deep  pectoral 
fascia  that  covers  the  pectoralis  major,  and  if  the  line  of  cleavage  is  followed 
the  dissection  is  quite  easy  as  betAveen  these  two  layers  there  is  only  loose 
connective  tissue.  The  breast  is  so  manipulated  with  the  left  hand  as  to 
expose  its  under  surface  completely.  If  a  growth  is  present  it  is  excised  in 
a  wedge-shaped  piece  of  tissue,  the  apex  of  the  wedge  being  toward  the 
nipple.  The  incision  is  carried  through  to  the  fatty  tissue  in  front  of  the 
gland  beneath  the  skin,  but  this  subcutaneous  fat  is  not  removed  as  it  aids 
in  reconstructing  the  breast  and  prevents  depression.  No  attempt  should 
ever  be  made  to  shell  out  the  tumor  because  it  is  sometimes  difficult  and  is 
always  likely  to  leave  a  portion  of  the  capsule  of  the  tumor  behind,  and  there 
will  be  recurrence.  Besides,  there  may  be  small  tumors  or  matrices  of 
tumors  in  the  breast  tissue  adjoining  the  main  tumor.  If  there  are  many  small 
cysts  or  if  the  operation  is  for  chronic  cystic  mastitis  of  one  portion  of  the 
breast  the  rest  of  the  breast  should  be  explored  after  the  diseased  segment 


^Jour.  Am.  Med.  Assn.,  July  15,  1905. 
2Ann.  Surg.,  June,  1907,  p.  810. 


464 


OPERATIVE    SURGERY 


has  been  removed.  This  is  done  by  radiating  incisions,  beginning  about  the 
center  of  the  breast  and  carried  to  the  periphery  like  spolves  from  a  wheel. 
Small  cysts  can  be  excised  with  a  luiife  or  scissors  but  those  smaller  than  a 
pea  are  merely  opened  and,  according  to  Warren,  do  not  require  removal. 
After  removing  the  diseased  segment  usually  two  or  three  incisions  are  suffi- 
cient for  exploratory  purposes.  Exploratory  incisions  hardly  require  sutures 
because  they  drop  together  when  the  mammary  gland  is  replaced.  When  a 
segment  is  removed,  however,  or  tissue  of  any  amount  is  excised  the  wound  is 
closed  Avith  catgut  sutures.  If  in  operations  for  chronic  cystic  mastitis  the 
nipple  is  inverted  this  should  be  corrected  by  freeing  the  adhesions  of  the 
nipple  and  placing  a  purse-string  suture  under  the  nipple  to  evert  it.  The 
purse-string  suture  should  be  of  tanned  or  chromic  catgut.  The  sutures  are 
placed  first  on  the  portion  of  the  gland  nearest  the  skin,  then  the  capsule  and 
the  posterior  part  of  the  gland  are  sutured  with  interrupted  catgut  sutures. 
The  gland  is  replaced  and  anchored  along  the  edge  of  the  fascial  and  pectoral 
muscle  with  a  few  interrupted  catgut  sutures.    A  second  row  of  catgut  stitches 


Fig.    447. — Incision    of    Dean   Lewis   for   removal    of    the    mammary    gland    in   intracanalicular   papilloma. 

may  be  taken  through  the  superficial  fascia  before  closing  the  skin,  though  this 
is  not  always  necessary.  The  wound  is  closed  by  a  continuous  mattress 
suture  of  fine  tanned  catgut  or  by  silk  or  silkworm-gut  if  it  is  preferred. 
Drainage  is  instituted  by  a  small  tube  at  the  outer  upper  angle  of  the  wound, 
as  the  large  raw  surface  nearly  always  results  in  the  accumulation  of  bloody 
serum. 

This  operation  should  not  be  done  where  there  is  any  reasonable  sus- 
picion of  malignancy.  Where  there  seems  to  be  no  doubt  about  the  benign 
nature  of  the  growth  and  where  chronic  cystic  mastitis  appears  localized 
to  one  quadrant  of  the  breast  the  operation  of  Warren  has  a  distinct  field 
of  usefulness. 

Excision  of  the  breast,  particularly  where  there  is  a  small  growth  which 
causes  a  bleeding  nipple,  can  be  done  with  but  little  deformity  by  the  opera- 
tion of  Dean  Lewis. ^  Bleeding  nipple  occurs  most  frequently  after  intra- 
canalicular papilloma   and   sometimes   after   certain   types   of   chronic    cystic 

^Surgical   Clinics  of   Chicago,   Feb.,    1917,   Philadelphia,   W.   B.    Saunders   Co.,   pp.    117-124. 


THE    MAMMARY    GLAND 


465 


mastitis.  There  shoiiUl  he  no  reasonahh;  ch)uht  that  the  growth  is  heiiign. 
Bloody  disoliarge  from  llie  uippk;  is  exceedingly  rare  in  any  cancer  but  if 
cancer  is  present  the  other  signs,  such  as  retraction  of  the  skin  and  compara- 
tive immobility  of  the  groAvth  should  suggest  the  correct  diagnosis.  In  a 
persistently  bleeding  nipple  even  without  a  palpable  growth  it  may  be  pre- 
sumed that  tiun'e  is  an  intracanalicular  papilloma.  Usually  Ihere  is  a 
small  growth  rather  superficial  and  beneath  the  nipple  or  the  areola  of  the 
nipple.  The  next  most  common  cause  is  chronic  cystic  mastitis.  Lewis 
employs  an  incision  at  the  junction  of  the  areola  with  the  skin  to  the  inner 
side  of  the  nipple  (Fig.  447).  The  areola  is  dissected  up  and  the  ducts  are 
cut  as  they  enter  the  nipple.  The  tissues  of  the  mammary  gland  are  grad- 
ually pulled  out  Avhile  the  dissection  is  carried  between  the  mammary  gland 


Fig.   448. — The   mammary   gland   is  being  freed.      (Dean   Lewis.) 

and  the  fat  (Fig.  448).  The  whole  mammary  gland  can  be  removed  in  this 
way.  After  the  operation  is  completed  the  wound  is  closed  by  a  series  of 
purse-string  sutures  of  catgut  placed  from  beloAv  upward  in  the  fat  that  was 
adjacent  to  the  breast.  With  three  or  four  purse-string  sutures  the  tissues 
are  so  reconstructed  as  to  leave  but  little  deformity  (Figs.  449  and  450).  The 
flap  of  the  areola  is  sutured  in  position  and  the  wound  is  not  usually  drained, 
though  there  is  considerable  discharge  of  serum  for  some  days  after  the 
operation.  Lewis  thinks  that  iDcrhaps  a  small  cigarette  drain  would  be 
advisable. 

Hernia  of  the  breast  is  a  condition  that  occasionally  occurs  when  the 
fascia  around  the  areola  and  the  nipple  gives  way  and  allows  a  bulky  pro- 
trusion of  the  mammary  gland  substance.    M.  L.  Harris*  operates  under  local 


■^Surgical   Clinics   of   Chicago,    October,    1917,  Philadelphia,   W.   B.    Saunders   Co.,   pp.   959-963. 


466 


OPERATIVE    SURGERY 


anesthesia  by  using'  four  small  incisions  radiating  from  the  nipple,  so  placed  as 
to  divide  the  circumference  of  the  areola  into  four  equal  parts.  These  in- 
cisions are  about  a  third  of  an  inch  in  length  and  extend  through  the  skin 
just  within  the  ring  of  the  subcutaneous  fascia  through  which  the  breast  tissue 
tends  to  escape.    A  long  straight  needle  threaded  Avith  silk  is  inserted  through 


Fig.   449. — The   mammary   gland  has   been  excised  and  pursestring  sutures   are   inserted   in   the   surrounding 

fat.      (Dean  Ivewis.) 

one  of  the  incisions,  picks  up  the  edge  of  the  ring  of  the  fascia,  and  is 
brought  through  the  neighboring  incision,  several  bites  being  taken  in  the 
ring.  After  bringing  out  the  needle  through  an  adjoining  incision  it  is  re- 
inserted in  a  similar  manner  through  each  quadrant   of   the   areola,   taking 


Fig.    450. — The    purse-string    sutures    have    been    tied,    so    obliterating    the    cavity    left    by    removal    of    the 

mammary  gland.      (Dean  Lewis.) 


care  to  catch  as  many  bites  as  possible  in  the  ring  of  fascia  which  permits  the 
hernia.  M^hen  the  needle  has  returned  to  the  point  of  beginning  three  more 
sutures  are  placed  in  a  similar  way,  each  one  a  little  farther  out  than  the  pre- 
ceding suture.    After  all  are  jDlaced  they  are  drawn  up  snugly  and  narrow  the 


THE    MAMMARY    GLAND  467 

ring  to  a  tlianietor  that  leaves  it  just  large  enough  for  a  free  passage  of  the 
milk  duets  to  llie  nipple.  The  threads  are  then  tied  and  the  ends  cut  short. 
The  iiu'isioiis  are  closed  A\ith  fine  silk  or  fine  silkworm-gut. 

When  there  is  suspicion  of  malignancy  a  direct  incision  to  the  tumor 
should  always  be  made  so  as  to  go  through  as  little  tissue  as  possible.  The 
incision,  Avhich  is  radiating,  is  carried  down  to  the  neigh])orhood  of  the 
tumor  and  then  the  growth  is  carefully  approached  to  avoid  incising  it  un- 
til a  view  can  be  had  of  the  tissues  in  its  immediate  vicinity.  Often  if  it 
is  cancerous  the  infiltration  is  detected  before  the  main  growth  is  actually 
opened.  If  it  is  a  cyst,  and  particularly  the  "blue  dome"  cyst  of  Blood- 
good,  a  careful  incision  gives  the  characteristic  appearance  before  the  cyst 
is  opened.  If  the  growth  is  still  suspicious  and  a  frozen  section  is  necessary 
to  decide  the  diagnosis,  a  small  piece  of  tissue  is  removed  from  the  suspicious  por- 
tion. The  raw  surface  should  then  be  immediately  cauterized  with  the  elec- 
tric cautery  or  mopped  out  with  carbolic  followed  with  alcohol.  If  the  growth 
proves  to  be  benign  the  whole  raw  surface  is  excised  as  in  a  debridement 
operation,  for  the  cauterized  raw  surface  will  not  heal  satisfactorily.  The 
growth  should  be  removed  along  with  surrounding  healthy  mammary  tissue 
and  after  careful  hemostasis  the  wound  is  closed  with  catgut  sutures,  taking 
particular  care  to  approximate  the  deep  layers  of  the  mammary  gland  ac- 
curately to  avoid  leaving  a  dead  space.  The  superficial  portions  of  the  mam- 
mary gland  are  sutured  separately  and  the  skin  is  closed  with  a  fine  subcuticular 
suture  of  silkworm-gut  or  interrupted  sutures  of  fine  silk.  If  a  subcuticu- 
lar suture  is  used  it  is  best  to  insert  a  few  strands  of  silkworm-gut  at  one 
end  of  the  wound  to  conduct  away  the  serum  and  broken  down  fat  that 
accumulates  after  these  operations. 

If  the  growth  proves  malignant  the  skin  wound  is  closed  with  forceps  af- 
ter packing  the  cavity  with  gauze  and  a  radical  operation  for  cancer  of  the 
breast  is  done. 

There  are  occasional  indications  for  removal  of  the  mammary  gland 
with  the  nipple  but  without  the  necessity  of  a  radical  operation,  as  after  tubercu- 
losis or  large  multiple  benign  tumors,  or  in  extensive  chronic  cystic  mastitis  with- 
out malignant  degeneration.  This  is  done  by  an  oval  or  elliptical  incision  whose 
axis  is  betAveen  the  axilla  and  the  navel.  The  skin  incisions  are  dissected  up  on 
each  side,  retaining  as  much  fat  under  the  skin  as  possible  and  at  the  same  time 
bearing  in  mind  that  the  edges  of  the  mammary  gland  often  extend  farther  than 
they  appear  to  extend.  After  reaching  the  pectoral  fascia  the  breast  is  dissected 
preferably  from  below  up  and  then  from  within  outward  and  is  completely 
removed.     The  skin  Avound  is  closed  in  the  usual  manner. 

The  radical  operation  for  cancer  of  the  breast  Avas  first  put  on  a  satis- 
factory basis  by  the  Avork  of  Halsted,  of  Johns  Hopkins.  His  analysis  of 
the  statistics  of  Billroth  and  others  showed  that  there  was  a  local  recurrence 
in  the  scar  or  in  the  skin  near  the  scar  in  from  80  to  90  "per  cent  of  the  cases. 
Halsted  became  convinced  that  the  operation  should  be  so  planned  as  to  re- 
move not  only  the  breast  but  the  adjacent  structures  including  a  Avide  ex- 


468  OPERATIVE    SURGERY 

cision  of  skin,  both  pectoral  muscles,  and  the  contents  of  the  axilla  in  one 
mass.  Will}'  Meyer,  of  New  York,  indepcndoitly  employed  the  same  prin- 
ciples about  the  same  time  and  described  an  operation  in  which  he  began 
dissection  at  the  axilla  instead  of  at  the  inner  portion  of  the  breast  as  in 
the  Halsted  operation. 

In  the  original  operation  of  Halsted  an  incision  was  made  which  sur- 
rounded the  breast,  taking  as  much  skin  as  possible.  The  incision  was  car- 
ried at  once  through  the  fat,  was  then  prolonged  at  a  tangent  to  the  inner 
portion  of  the  incision  and  carried  over  the  pectoral  muscle  to  a  point 
about  opposite  the  apex  of  the  axilla.  This  incision,  however,  has  been 
changed  by  Halsted  so  that  it  never  goes  down  the  arm,  as  was  originally 
recommended,  and  consequently  the  triangular  flap  of  skin  has  been  aban- 
doned. A  short  vertical  cut  to  the  clavicle  is  made  instead.  If  the  sur- 
rounding incision  is  extensive  and  wide  this  vertical  incision  is  unneces- 
sary. The  abandonment  of  the  incision  down  the  arm  avoids  the  contraction 
of  the  scar  through  the  axilla,  which  not  only  interferes  with  the  motion 
of  the  arm  but  sometimes  produces  discomfort.  The  incision  in  the  skin,  then, 
is  placed  to  surround  the  breast  with  the  malignant  grow^th,  and  not  the 
nipple,  as  the  center.  A  vertical  cut  is  made  to  the  clavicle  and  another  un- 
der the  axilla  if  necessary  to  expose  the  axilla  satisfactorily.  The  origin  of 
the  major  pectoral  from  the  ribs  is  divided  and  the  clavicular  portion  of 
the  muscle  is  split  to  a  point  about  opposite  the  scalene  tubercle  of  the  first 
rib  where  it  is  cut  across  up  to  the  clavicle,  thus  exposing  the  apex  of  the 
axilla.  The  loose  tissue  under  the  clavicular  portion  of  the  pectoral  major 
is  dissected  from  the  muscle  and  is  included  in  the  mass  to  be  excised,  for  this 
tissue  contains  many  lymphatics  and  may  be  infected  with  cancer.  The  inser- 
tion of  the  pectoralis  major  is  severed  close  to  the  humerus,  then  the  insertion 
of  the  pectoralis  minor,  and  the  whole  mass,  including  the  skin,  breast  and 
muscle,  is  raised  and  stripped  from  the  thorax  as  close  to  the  ribs  as  possible. 
The  minor  pectoral  muscle  is  included  in  the  mass  to  be  removed.  The  axilla  is 
dissected  from  within  outward  and  from  above  downward,  using  a  sharp 
knife  and  stripping  the  axillary  vein  clean.  After  clearing  the  axillary  vein 
the  axilla  is  dissected  on  its  inner  wall  and  then  its  posterior  wall  from  within 
outward.  The  subscapular  vessels  are  usually  clamped  and  divided.  The 
subscapular  nerves  may  be  divided  or  saved  depending  upon  the  indications 
at  the  time.  The  mass  is  completely  removed  by  severing  the  outer  and 
lower  attachments  of  the  fascia  of  the  pectoral  muscles.  Halsted  then  ad- 
vises an  incision  along  the  posterior  margin  of  the  sternomastoid  muscle, 
which  divides  a  few  of  the  fibers  of  the  muscle  and  exposes  the  junction  of 
the  internal  jugular  and  the  subclavian  veins.  The  omohyoid  muscle  is  divided 
and  retracted  and  the  supraclavicular  fat  is  removed  by  dissecting  down- 
ward and  outward  from  the  junction  of  the  internal  jugular  and  subclavian 
veins.  The  infraclavicular  fat  is  dissected  up  from  below.  By  elevating  or 
lowering  the  shoulder  the  clavicle  can  be  raised  or  lowered  and  the  tissue 
which  binds  the  subclavian  vein  to  the  clavicle  can  be  put  on  a  stretch  and 


THE    MAMMARY    GLAND 


469 


removed  while  the  fiiiger  is  passed  beneath  the  clavicle.  Any  fat  or  overlooked 
fascia  is  demonstrated  and  removed.  The  fat  along  the  inner  and  posterior  bor- 
der of  the  scapnla  between  the  serratus  magnus  and  the  subscapular  muscles  is 
also  removed.  The  wound  in  the  neck  is  sutured.  Particular  care  is  taken  to 
suture  the  skin  around  the  axilla  while  the  arm  is  held  outward  and  up- 
ward. The  flap  of  skin  next  to  the  axilla  is  so  manipulated  that  it  Avill 
line  the  apex  of  the  axilla  and  protect  the  vessels.  This  presents  later  ax- 
illary contraction.  The  lower  portion  of  the  wound  is  approximated  as  much 
as  possible  with  sutures.  The  rest  of  the  raw  surface  is  covered  with  Thiersch 
skin  grafts. 

The  operation  of  Halsted  has  given  results  that  were  greatly  superior  to 
any  other  operation  used  at  that  time.     It  was  founded  on  an  accurate  con- 


Fig.   451. — Lines   of  incision   for  operation  of  Jackson   for   cancer  of   the   breast. 

ception  of  the  pathology  of  cancer  and  the  anatomy  of  the  tissue  involved. 
There  are  apparently  advantages,  however,  in  planning  the  operation  so  that 
the  dissection  can  be  begun  at  the  axilla  instead  of  at  the  upper  and  inner 
border  of  the  mammary  gland.  The  operation  of  Jackson  embodies  this 
principle  and  has  given  excellent  results.  Here  an  incision  is  made  in  such 
a  manner  that  a  quadrangular  flap  of  skin  is  left  with  its  base  from  the 
clavicle  near  the  shoulder  to  a  point  near  the  sternum  (Fig.  451).  After 
excision  of  the  mammary  gland  with  the  pectoral  muscles  and  the  contents  of 
the  axilla,  this  ciuadrangular  flap  is  turned  down  in  position,  so  covering 
the  wound. 

There  is  serious  objection  to  any  operation  for  malignant  growths  that 
is  planned  with  the  closing  of  the  wound  as  one  of  the  chief  objects  in  view. 
As  Halsted  has   said  it   would  be   better   to   have   one   surgeon   remove   the 


470 


OPERATIVE    SURGERY 


cancer  and  another  to  close  the  wound,  so  the  former  would  be  unhampered  by 
the  thought  of  covering  the  raw  surface  after  he  had  extirpated  the  disease. 
In  recent  years  I  have  done  with  much  satisfaction  the  operation  de- 
scribed by  the  late  W.  L.  Rodman.  This  operation  is  based  primarily  upon 
the  principle  of  extirpating  the  diseased  tissue  in  one  mass.  Sampson  Hand- 
ley's  researches  have  shown  that  cancer  not  only  grows  along  the  main 
lymphatic  trunks,  but  radiates  in  the  subcutaneous  tissue  from  the  original 
focus.  The  cancer  cells  instead  of  migrating,  grow  from  the  base  in  long 
columns  and  the  cells  nearest  the  original  focus  of  disease  may  perish  and 
obliterate  the  lymphatic  channels  in  which  they  grew.  A  strip  of  subcuta- 
neous tissue  radiating  from  the  original  focus  of  cancer  may  frequently  be 
found  to  contain  cancer  cells  not  near  the  tumor,  but  at  a  point  several  inches 
from  the  growth.     It  has  also  been  demonstrated  that  cancer  of  the  breast 


Fig.    452. — Lines   of  incision    for   operation    of   Rodman    for   cancer   of    the   breast. 

rarely  if  ever  metastasizes  through  the  blood  stream,  but  uses  the  lymphatic 
channels  and  continuity  of  tissues  for  growth.  Metastases  in  the  liver,  for  in- 
stance, probably  come  from  the  breast  through  the  tissues  around  the  ensi- 
form  cartilage  and  thence  to  the  liver  through  the  lymphatics.  Metastases  in 
the  bones  of  the  vertebra?  come  to  their  destination  through  the  subcutaneous 
and  deeper  tissues  around  the  chest  wall.  The  object  of  the  operation,  then,  is 
first  of  all  to  remove  this  potentially  cancer  bearing  tissue  and  to  remove  it 
in  one  mass,  so  that  the  edges  of  the  specimen  will  contain  healthy  tissue 
and  will  surround  all  the  cancer  cells. 

In  the  operation  of  Rodman  a  straight  incision  is  made  from  about  an  inch 
below  the  clavicle  downward  and  outward,  two  inches  from,  and  parallel 
to,  the  sulcus  between  the  deltoid  muscle  and  the  upper  part  of  the  major 
pectoral.     This  incision   extends  well  below  the  free   edge   of  the   pectoral 


THE    MAMMARY    GLAND 


471 


muscle  and  is  about  six  inelies  in  length,  sometimes  longer.  The  incision 
is  carried  down  through  the  skin  to  the  fascia  covering  the  pectoral  mus- 
cle. It  should  not  be  placed  too  close  to  the  arm  because  of  the  possible 
discomfort  of  the  subsequent  scar  (Fig.  452).  The  outer  portion  of  the  incision 
is  strongly  retracted  by  a  broad  retractor  and  the  index  finger  of  the  left 


Fig.    453. — The    axilla   is    exposed   and    dissected    from    above    downward,    leaving    the    long    subscapular    and 
the  posterior   thoracic  nerves.      (W.   L.   Rodman.) 


hand  is  introduced  under  the  major  pectoral  near  its  insertion  and  the  muscle 
is  divided  close  to  the  humerus.  Sometimes  a  portion  of  the  muscle  near 
the  clavicle  can  be  left  and  will  not  interfere  with  the  dissection,  or  with 
the  chances  of  recurrence,  though  if  the  growth  is  near  the  muscle  it  will 
be  safer  to  remove  the  whole  pectoralis  major.  While  still  strongly  re- 
tracting the  outer  edge  of  the  incision  in  the  skin,  the  minor  pectoral  mus- 


472  OPERATIVE    SURGERY 

cle  is  identified,  separated  from  its  fascia,  and  divided  in  a  similar  manner. 
The  long  thoracic  artery  runs  in  the  fascia  parallel  with,  and  just  below, 
the  tendon  of  the  minor  pectoral  and  unless  this  fascia  is  separated  from 
the  muscle  before  the  tendon  is  divided  this  artery  maj-  be  injured.  The 
acromiothoracic  artery  is  just  above  the  tendon  and  this  too  should  be 
protected.  Both  of  these  arteries  will  be  easily  avoided  by  dissecting  the 
fascia  from  the  tendon  of  the  pectoralis  minor  before  the  finger  is  in- 
serted beneath  it.  then  lifting  up  the  tendon  strongly  and  dividing  it  close 
to  its  insertion  into  the  coracoid  process.  The  outer  portion  of  both  pec- 
toral muscles  is  strongly  retracted  inward  and  the  axilla  is  dissected  by 
opening  the  costocoracoid  membrane  and  beginning  the  dissection  at  the 
apex  of  the  axilla  around  the  axillary  vein.  The  cephalic  vein  at  the 
upper  and  outer  part  of  the  wound  should  not  be  injured.  Dissection 
is  made  from  above  downward,  removing  the  fat  and  fascia  carefulh'  from 
the  vein,  using  a  sharp  knife  near  the  vessels  and  then  gauze  for  blunt 
dissection.  Eodman  advises  the  use  of  gauze  entirely  in  the  upper  third  of 
the  axilla,  though  with  a  careful  exposure  dissection  with  a  sharp  knife  is  more 
satisfactory.  As  the  axillary  vessels  are  cleared  from  above  do^vnward  the  acro- 
mial, alar  thoracic,  and  the  subscapular  branches  of  the  axillary  artery  are  en- 
countered in  the  order  named  from  above  downward.  These  arteries  with 
their  accompanying  veins  are  doubly  clamped  and  divided.  The  large  lym- 
phatic glands  are  usually  found  at  the  base  of  the  axilla.  The  whole  con- 
tents of  the  axilla,  including  the  glands,  is  carefully  dissected  from  the  axil- 
lary walls,  taking  the  fascia  over  the  muscles  and  leaving  nothing  on  the  inner 
wall  of  the  axilla  except  the  posterior  thoracic  nerve,  which  should  be  pre- 
served (Fig.  453 j.  In  this  way  the  blood  supply  to  a  large  portion  of  the  tis- 
sues as  well  as  the  main  lymphatic  trunks  along  the  axilla  are  controlled  first, 
which  is  not  done  when  the  dissection  is  made  from  the  sternum  first  in- 
stead of  from  the  axilla. 

The  middle  or  long  subscapular  and  the  posterior  thoracic  nerves  are  pre- 
served. The  posterior  thoracic,  which  supplies  the  serratus  magnus,  and  the 
long  subscapular,  which  supplies  the  latissimus  dorsi,  are  important.  They  run 
along  the  walls  of  the  axilla,  and  not  through  the  axilla,  so  their  preservation 
does  not  impair  the  efficiency  of  the  operation  so  far  as  block  dissection  and 
curing  cancer  are  concerned  and  at  the  same  time  conserves  the  usefulness 
of  two  large  and  important  muscles.  If  these  nerves  are  spared  the  move- 
ment of  the  shoulder  joint  will  be  but  slightly  if  at  all  impaired. 

After  completing  the  dissection  of  the  axilla  the  second  skin  incision  is  made 
by  beginning  about  the  middle  of  the  initial  incision,  going  around  the 
breast,  and  ending  below  the  ensiform  cartilage  about  half  way  to  the  navel. 
The  edge  of  this  incision,  distal  to  the  tumor,  is  dissected  up  close  to  the 
skin,  the  incision  being  made  in  such  a  manner  that  it  goes  only  through  the 
deep  layers  of  the  skin.  The  subcutaneous  tissue  is  undermined  for  several  inches, 
keeping  as  close  to  the  skin  as  possible  CFig.  454).  In  this  way  the  sub- 
cutaneous tissue  that  has  been  shown  by  Handley  to  be  very  likely  to  con- 


THE    MAMMARY    GLAND 


473 


tain  c 


aneer  cells  is  blocked  out  to  ho  romoved  alono^  .villi  the  mammary  -land. 

removing'  an  innisual  amount  of  the 
val   i>r  llu'  subcutaneous  fat  and  fas- 


This  point  is  even  move  imporlani    llian 
skin  itself  and  Avitli  llu"  extensive  renu) 


Fig    454 -The   incisions  are   extensively   undermined   in   order   to   remove   as   much   of   the  subcutaneous   fat 
^"  and   fascia  as  possible.      (Rodman.) 


cia  recurrences  are  probably  fewer  than  where  a  somewhat  more  extensive 
removal  of  the  skin  is  done  without  the  undermining  dissection  for  the  sub- 
cutaneous tissue.  Incidentally  the  undermining-  makes  it  easier  to  close  the 
wound.     This,  however,  is  a  minor  consideration. 


474 


OPERATIVE   SURGERY 


The  third  incision  begins  at  the  outer  extremity  of  the  initial  incision 
as  the  second  incision  began  about  its  middle.    This  is  carried  dowmvard  and 

imvard   and   meets  the   second   incision  at   an   acute   angle   about   half  way 
between  the  ensiform  cartilage  and  the  umbilir-iis.     This  inr-ision  also  is  car- 


Fig.    455. — The   breast    -.vith    its    covering   of    skin,    the   contents    of    the    axilla,    a    portion    of    the    sheath    of 
the  rectus  muscles,  and  the  adjoining  fat  and  fascia  have  been  removed  in  one  mass.     (Rodman.) 

ried  only  through  the  skin,  and  the  subcuticular  tissue  is  carefully  under- 
mined and  dissected  from  the  skin  for  several  inches,  as  along  the  second 
incision.  The  tissues  are  then  removed  from  above  downward,  cutting  the 
subcuticular  tissue  down  to  the  deep  fascia  along  the  extremity  of  the 
undermined  dissection,  which  should  be  at  least  three  inches  from  the  edge 
of  the  skin  incision.      This  includes  the   fascia   over   the   sternum.      The   or- 


THE    MAMMARY    GLAND 


475 


igin  of  the  major  pectoral  muscle  is  severed  and  the  perforating  arteries 
are  clamped.  The  fascia  of  the  upper  portion  of  the  recti  muscles  and  some 
of  the  fat  betAveen  these  muscles  are  included  in  the  hlock  dissection.  The 
origin  of  the  minor  pectoral  is  severed  close  to  the  ribs  while  holding  the 
muscle  up  with  the  finger  to  make  it  tense.  The  fascia  along  the  edge  of  the 
serratus  magnus  is  dissected  to  the  outer  limits  of  the  undermined  incis- 
ion (Fig.  455).  Care  must  be  taken  to  include  all  fascia  over  the  thorax  and 
below  the  clavicle  in  this  mass,  as  this  fascia  is  particularly  likely  to  harbor 
cancer  cells. 

The  specimen  is  removed  and  should  contain  in  one  mass  the  mammary 


Fig.  456. — Photograph  of  patient  of  the  author  on  whom  the  Rodman  operation  was  done,  taken 
eleven  months  after  the  operation.  Note  the  line  of  scar  which  shows  that  the  incision  was  completely 
closed  at  the  time   of   operation,  and  the   mobility   of   the   arm,   which   is  unimpaired   by    the    operation. 

gland,  with  the  cancer  about  the  center  of  the  excised  skin,  the  pectoral 
muscles  and  the  contents  of  the  axilla  attached  to  one  end  of  the  specimen, 
with  a  wide  zone  of  subcutaneous  fat  and  fascia  surrounding  the  breast 
internally,  above,  and  below,  as  well  as  the  fascia  over  the  upper  portion  of 
the  recti  muscles.  The  recti  muscles  should  first  be  approximated  by  in- 
terrupted sutures  of  catgut  and  the  clamped  vessels  are  tied  with  catgut.  The 
sutures  of  the  skin  begin  at  the  lower  angle  and  are  interrupted  silkworm- 
gut.  They  are  placed  from  below  upward  until  the  tension  becomes  great. 
Before  sutures  are  placed  over  the  axillary  region  a  stab  wound  is  made  in  the 
skin  over  the  lower  portion  of  the  axilla  and  a  rubber  drainage  tube  is  carried 
through  the  stab  wound  and  fastened  in  position  by  suturing  it  to  the  skin.    This 


476  OPERATIVE    SURGERY 

not  only  provides  for  drainage,  but  tends  to  produce  a  flow  of  lymph  toward  the 
tube  and  may  in  this  way  cause  the  washing  out  of  cancer  cells  that  might 
otherwise  be  absorbed.  After  the  wound  has  been  sutured  about  half  Avay 
from  below,  suturing  is  begun  at  the  upper  angle,  interrupted  sutures  of 
silkworm-gut  being  placed  from  this  point  down  to  the  region  of  greatest 
tension.  The  sutures  are  introduced  in  such  a  manner  as  will  provide  for 
free  movement  of  the  shoulder  and  at  the  same  time  not  produce  too  much 
tension.  A  fold  of  skin  that  runs  backward  can  be  sutured  so  as  to  re- 
lieve the  tension.  The  principles  of  plastic  surgery  are  utilized  in  closing 
this  Avound.  It  is  wise  never  to  have  too  fixed  a  rule  for  suturing  such  cases,  as 
the  amount  of  skin  to  be  removed  is  regulated  by  the  extent  and  location  of  the 
growth.  At  points  of  tension  caused  by  the  sutures  short  relaxation  incisions  are 
made,  carrying  the  knife  just  through  the  skin  and  making  the  incision  no  longer 
than  one-eighth  or  at  most  one-fourth  of  an  inch.  If  this  is  done  freely  along 
the  lines  of  tension,  as  shown  by  the  appearance  of  white  areas  after  the 
stitches  are  tied,  venous  drainage  is  promoted  and  there  is  but  little  likeli- 
hood of  breaking  down  of  the  wound  on  account  of  lack  of  nutrition.  It  is 
well,  however,  to  cover  the  wound  with  some  sterile  impervious  material 
which  may  be  left  on  for  four  days  and  Avill  favor  the  nutrition  of  the  skin 
along  the  suture  line  somcAvhat  better  than  a  simple  dry  dressing.  If,  how- 
ever, the  nutrition  along  the  edges  of  the  wound  seems  to  be  well  established 
an  ordinary  dry  dressing  may  be  placed,  taking  care  to  reinforce  the  dressing 
along  the  exit  of  the  tube.    The  tube  is  removed  in  five  or  six  days  (Fig.  456). 


CHAPTER  XXII 
OPERATIONS  FOR  HERNIA 

The  emergency  of  hernia  is  clue  to  stranguUition,  and  this  may  occur  with 
almost  any  type  of  hernia.  The  strangulation  calls  for  immediate  operation. 
After  this  is  relieved  the  method  of  dealing  with  the  bowel  or  omentum  which 
Avas  strangulated  depends  partly  upon  the  condition  of  the  imprisoned  struc- 
tures and  partly  upon  the  condition  of  the  patient. 

Strangulated  inguinal  hernia  frequently  occurs  because  of  the  great  in- 
cidence of  inguinal  hernia,  but  proportionately  the  number  of  cases  of  stran- 
gulation of  the  femoral  and  umbilical  hernias  represents  a  higher  percentage. 
The  smaller  the  opening  through  which  a  hernia  protrudes  the  greater  the 
probability  of  strangulation,  solely  for  mechanical  reasons,  whereas  a  large 
bulging  hernia  that  may  afford  great  discomfort  is  not  likely  to  be  strangulated 
unless  there  are  bands  or  adhesions  in  the  neck  of  the  sac  through  which  special 
loops  are  caught,  or  unless  there  are  adhesions  to  a  portion  of  the  sac  which 
fix  the  bowel  at  this  point  and  predispose  to  a  volvulus. 

If  the  strangulation  is  in  an  inguinal  or  a  femoral  hernia  an  incision  is 
made  parallel  wdtli  and  just  above  Poupart's  ligament.  In  an  inguinal  hernia, 
after  dividing  the  skin  and  superficial  fascia,  the  aponeurosis  of  the  external 
oblique  is  split  with  scissors  or  with  a  knife  on  a  grooved  director.  Blunt- 
pointed  scissors  are  the  most  satisfactorj^  instrument.  The  ring  of  con- 
striction is  divided  by  splitting  it  in  an  upward  direction  until  the  con- 
striction is  entirely  relieved.  The  sac  of  a  strangulated  hernia  is  recognized 
by  subperitoneal  fat  that  is  usually  immediately  over  it,  by  its  bluish  color, 
and  by  the  fact  that  it  is  thin  and  almost  transparent  and  can  be  seen  to 
glide  over  the  contents  beneath  it.  The  sac  should  always  be  opened,  but 
it  is  best  first  to  divide  the  constriction.  Sometimes,  hoAvever,  the  tenseness 
of  the  sac  from  its  contained  bowel  and  fluid  is  so  great  that  it  is  wiser  to 
open  the  sac  before  attempting  to  relieve  the  constriction.  If  it  is  a  direct 
inguinal  hernia,  care  must  be  taken  to  avoid  injuring  the  deep  epigastric 
artery  which  lies  to  the  outer  side  of  the  neck.  In  indirect  hernia  no  such 
structure  is  present  but  a  division  of  either  type  of  hernia  by  carefully 
cutting  down  from  without  inward  will  make  any  vessel  accessible,  so  its 
injury  can  either  be  avoided  or  the  vessel  can  be  readily  clamped  and  tied. 

In  femoral  hernia  the  so-called  hernia  knife  or  blunt-pointed  bistoury  is 
often  used.  The  femoral  canal  cannot  be  freely  divided  without  considerable 
danger  of  recurrence  of  the  hernia.  It  is  best  in  this  type  to  make  the  same 
incision  as  in  inguinal  hernia  and  after  retracting  the  lower  margin  of  the 
wound  to  expose  and  free  the  sac.     The  abdomen  is  then  opened  and  an  ef- 

477 


478  Ol'KKATUM':    RUROERY 

fort  is  iiKulc  ;il  I'cduclion,  i);iflly  by  iii;mipiil;il  ion  ol"  tlio  sac  Miul  ])artly 
by  piilliiiii'  on  the  inlcstinc  lliroii^li  the  ;il)(h)ininal  incision.  Willi  iliis  ])imanual 
manipulation  many  femoral  liernias  can  be  I'cchiced.  If  this  procediii'ii  is  of 
no  iiNiiil  the  femoral  rini;'  can  be  nicked  with  a  binnt -point  ed  bislonry  or  a 
knife  carried  down  on  a.  grooveil  director  or  by  l)hiid.  scissors.  The  hernia 
knife  may  be  inserted  in  the  femoral  eanal  from  above  after  cleariiifj;'  Pon- 
])ai'l.'s  liii'juueid  and  a  cnt  is  niad(>  inward  in  the  direction  of  the  libers  (»f  tlu^ 
li^'ameid.  The  o|)(Mnni>'  is  then  more  readily  I'cpaired  than  if  the  eanal  were  cnt 
npwai'd  across  Poni)art's  lif^amcnt. 

In  nnd)ilical  hernia  the  same  t^'cneral  pi'ineiples  apply.  The  di\ision  of 
the  conslrictint''  rin^i;'  shonld  b(>  onlward  so  that  the  margins  of  the  rin<;'  can 
be  overlapped  from  above  dow  invard. 

In  acquired  incisional  or  \-enl  I'ai  hernia  followini;' eit  licr  accident  or  opera- 
tion stranfi'ulation  is  not  a  fre(pnMd  oecnrrence,  thoni^li  on  acconnt  of  adhesions 
obstruction  of  the  bowel  may  occur. 

After  reduction  of  the  contents  of  a  strangulated  hernial  sac  lli(>  bowel  shonld 
always  be  inspected.  ]f  there  is  a  suspicion  of  gangrene  and  no  perforation  of  the 
bowel,  it  is  best  to  return  the  suspicious  loop  to  the  abdominal  cavity  just  beneath 
the  incision  for  a  few  minutes.  Then  the  loop  is  inspected  and  if  the  color  has 
improved  and  it  seems  that  the  loop  will  recover,  the  hei-nia  is  treated  according 
to  the  indications,  and  the  boM^el  is  further  disregai-dcd.  If  the  bowel  appears 
gangrenous,  or  if  tlvere  is  a  suspicion  of  perforation,  the  boM'cl  shoidd  not  be 
r(>turned  to  the  abdominal  caxity,  but  is  surrounded  for  fi\-e  minutes  to  ten 
minutes  with  gau/e  Avriuig  out  of  hot  salt  solution,  or  if  the  condition  of 
the  ])atient  permits,  until  it  is  apparent  what  Avill  be  the  elT'ect  of  the 
stra]igulali(ui  on  the  bowel.  Often  when  a  loop  looks  cx'cn  doubtful  ol'  re- 
covery, it  will  clear  up  after  such  tnvitment.  If  the  bowel  is  fraidcly  gangrenous 
or  threatens  to  perforate  and,  of  course,  if  a  perforation  has  actuially  oc- 
curred, the  surrounding  tissues  and  the  peritoneal  cavity  are  protected  b}^ 
being  packed  off  with  nu)ist  gauze  and  the  bowel  is  resected.  The  tech- 
nic  of  resection  is  described  in  the  chapter  on  Intestinal  Surgery.  A  care- 
ful resection  is  nuule,  A\itb  attention  to  closure  of  the  mesenteric  trian- 
gles of  the  bowel  before  opening  Ihe  intestine  and  severing  it  from  the  mesen- 
teric border  outward.  Union  can  be  rapidly  made  with  a  needle  and  thread. 
This  operation  can  be  done  under  a  local  anesthetic.  Ivcsection  is  usually 
])referable  to  a  large  fecal  fistula.  If  the  strangulation  has  existed  for  some- 
time and  if  the  bowel  on  the  proximal  side  of  the  strangulation  is  consid- 
erably dilated,  an  enterostomy  by  Ihe  method  that  is  described  in  the 
chapter  on  Intestinal  Surgery,  in  which  tln>  priiu'i])le  of  Coffey  is  employed, 
affords  the  greatest  saf(>ly.  This  may  be  done  with  or  without  a  resect i(ui. 
If  there  is  considerable  distention  of  the  bowel  and  resection  is  done  an 
enterostomy  shonld  always  be  ])crformed,  using  a  rubber  catheter,  making 
a  valve  enterostomy,  and  bringing  the  tube  through  a  stab  wound  either 
before  it  is  inserted  into  the  enterostomy  opening,  or  else  clani])ing  it  near 
the   l)ow(d    and    then    j)ringing    it   old    through    a    stab    wound.      In    this   way 


HERNIA 


479 


infection  of  the  tissues  from  the  fecal  contents  is  avoided.  If  a  large 
loop  of  bowel  is  strangulated  and  dilated  and  if  the  condition  of  the  bowel 
is  doubtful  after  waiting  several  minutes,  the  course  to  be  pursued  depends 
upon  the  ability  of  the  surgeon  and  the  condition  of  the  patient.  If  the 
surgeon  has  had  some  experience,  and  particularly  experience  in  animal  ex- 
perimentation, and  has  mastered  the  technic  of  resection,  it  is  probably  safer 
for  the  patient  if  resection  is  done.  If,  however,  the  surgeon  is  doubtful  of 
his  technic  and  has  had  little  or  no  experience  in  resecting  bowel,  it  would 
be  safer  to  return  the  doubtful  loop  and  let  the  patient  take  his  chances. 
In  frank  gangrene,  of  course,  resection  should  always  be  done. 

Whether  the  radical  cure  of  a  hernia  should  be  undertaken  after  the  relief  of 
the  strangulation  depends  largely  upon  the  condition  of  the  patient.  It  should  al- 
ways be  attempted  unless  there  is  strong  contraindication.  Where  the  bowel  has 
already  ruptured  and  the  tissues  have  become  infected  no  serious  attempt  at  rad- 
ical cure  should  be  made,  but  a  few  sutures  are  placed  to  retain  the  contents  of 
the  abdomen  and  the  wound  is  abundantly  drained,  being  packed  loosely  with 
gauze.  Later,  when  the  infection  has  been  fully  overcome,  an  operation  for 
radical  cure  can  be  done. 

INGUINAL  HERNIA 

A  type  of  hernia  that  is  frequently  incarcerated,  but  not  often  strangu- 
lated, is  "sliding"  hernia.  This  occurs  most  frequently  on  the  left  side, 
but  may  be  found  on  the  right  side.  It  is  possible  to  have  a  sliding  hernia 
of  large  bowel  with  a  loop  of  small  bowel  strangulated  in  the  sac.  The  path- 
ology of  sliding  hernia  must  be  understood  in  order  to  operate  upon  it  in- 
telligently. It  has  been  variously  explained  as  a  condition  in  w^hich  the 
large  bowel,  particularly  the  sigmoid,  slides  down  between  the  two  layers 
of  its  mesentery  and  appears  in  such  a  manner  that  the  wall  of  the  bowel  it- 
self forms  part  of  the  sac.  This  condition  has  been  very  satisfactorily  ex- 
plained by  Louis  Ransohot¥,  of  Cincinnati,  as  merely  a  fusion  and  disap- 
pearance of  the  peritoneal  coats.  This  is  quite  common  in  embryologic  de- 
velopment, and  is  often  seen  when  portions  of  the  ascending  or  descend- 
ing colon  are  so  closely  attached  to  the  abdominal  wall  by  the  fusion  of  the 
peritoneum  that  they  are  practically  as  much  extraperitoneal  organs  as  the 
kidneys.  Sliding  hernia  is  particularly  prone  to  recur  and  should  be  care- 
fully reduced  after  freeing  the  attachments  of  the  bowel  through  the  ring 
and  into  the  abdominal  cavity.  In  many  instances  the  portion  of  the  sac 
that  is  left  can  be  utilized  to  cover  the  raw  surface  of  the  sliding  bowel 
as  a  flap  somewhat  similar  to  the  method  used  in  the  ''bottle"  operation 
for  hydrocele.  The  relation  of  the  peritoneum  of  the  sac  to  a  sliding  hernia 
is  quite  similar  to  that  of  the  tunica  vaginalis  to  the  testicle. 

The  radical  cure  of  inguinal  hernia  has  an  interesting  history.  The  op- 
eration of  Bassini  has  stood  the  test  of  time  and  has  proved  satisfactory  in 
most  cases  of  inguinal  hernia.     The  only  modification  of  Bassini 's  technic 


480 


OPERATIVE    SL'RGERY 


that  appears  as  a  marked  improvement  is  the  substitution  of  the  absorbable 
suture  for  the  nonaljsorbable  silk  that  Avas  originally  used  by  Bassini.  While 
fine  silk  sutures  can  be  employed  without  the  proljability  of  trouljle  resulting, 
in  operations  on  hernia  stouter  material  must  be  used  and  tlie  larger 
nonabsorbable  sutures  are  likely  to  irritate  the  tissues  and  an  effort  to  extrude 
them  often  follows. 

The  principle  of  the  Bassini  operation  is  to  reconstruct  the  inguinal 
canal  by  suturing  the  conjoined  tendon  and  the  internal  oblique  and  trans- 
versalis  muscles  to  the  shelving  edge  of  Poupart's  ligament  beneath  the 
spermatic  cord,  -while  the  aponeurosis  of  the  external  oblique  is  brought 
together  over  the  cord.  An  incision  is  made  over  the  inguinal  canal  parallel 
to  Poupart's  ligament  and  about  half  an  inch  above  it  and  extending  from 
over  the  external  inguinal  ring  to  an  inch  beyond  the  region  of  the  internal 
ring   (Fig.  457).     If  the   operation  is  done  under   a   local   anesthetic,   which 


Fig.    457. — Line  of  incision  for  exposure  of  the  ingviinal   canal  in  the  Bassini   operation  for  inguinal   liernia. 


can  often  be  satisfactorily  used,  the  incision  should  extend  slightly  farther 
outward  than  under  a  general  anesthetic,  as  it  is  necessary  to  infiltrate 
the  ilioinguinal  and  the  iliohypogastric  nerves  in  an  "early  stage  of  the 
operation.  Here  the  fibers  that  lie  about  the  center  of  the  inguinal  canal  are 
identified  by  the  bulging  and  the  thinning  out  of  the  fibers  and  by  their 
position  in  regard  to  the  external  ring  and  are  split  with  a  knife  at  the 
outer  end  of  the  incision  (Fig.  458).  The  edges  of  the  split  fibers  are 
seized  with  hemostatic  forceps  and  gently  elevated,  while  the  tissues  be- 
neath are  separated  until  the  ilioinguinal  and  iliohypogastric  nerves  are 
identified.  Occasionally  one  or  the  other  of  these  nerves  is  absent  and 
not  infrequently  one  is  much  larger  than  the  other  one.  Their  course  and 
position  is  somewhat  variable,  but  they  can  usually  be  found  beneath  the 
split  portion  of  the  aponeurosis  of  the  external  oblique  about  two  or  three 
inches  from  the  external  ring  (Fig.  459).  These  nerves  are  infiltrated  with 
novocain  solution  through  a  fine  hypodermic  needle  if  the  operation  is  done 


HERNIA 


481 


under  local  anesthesia,  and  tlie  fibers  of  tlie  apoiienrosis  are  split  down  throngh 
tlie  external  ring.  In  operating  under  a  general  anesthetic  the  aponeurosis 
is  usually  split  from  the  external  ring  upward.  This  method  is  quicker  and 
somewhat  easier,  hut  not  infrequently  these  two  nerves  are  injured  when 
the  aponeurosis  is  cut  in  this  way  and  this  results  in  areas  of  anesthesia  and 
hyperesthesia  which  are  somewhat  annoying  to  the  patient.  "Whether  a 
general  anesthetic  or  a  local  anesthetic  is  used  an  effort  should  be  made  not 
only  to  preserve  these  nerves  but  to  avoid  their  being  included  in  the  su- 
tures that  approximate  the  structures  beneath  the  cord. 

The  edges  of  the  split  aponeurosis  are  separated  from  the  adjacent  tis- 


Fig.   458. — The   external   inguinal   ring  is  exposed. 

sue  below  and  above,  and  the  nerves  are  kept  under  observation  to  prevent 
injury.  The  iliohypogastric  penetrates  the  aponeurosis  of  the  external  oblique 
toward  the  inner  and  upper  portion  of  the  w^ound,  usually  about  an  inch  from 
the  margin  of  the  split  aponeurosis.  Unless  it  is  kept  under  observation  it 
may  readily  be  bruised  or  torn  where  it  enters  this  structure. 

After  laying  open  the  roof  of  the  inguinal  canal  by  splitting  the  fibers 
of  the  aponeurosis  of  the  external  oblique,  the  procedure  of  Bassini  is  the 
same  whether  a  local  or  a  general  anesthetic  is  employed.  To  avoid  pain 
particular  care  must  be  used  in  infiltrating  the  structures  around  the  internal 
inguinal  ring  and  around  the  neck  of  the  sac. 

The  cremaster  muscle  and  a  layer  of  transversalis  fascia  which  cover 
the  cord  and  the  sac  are  divided,  and  the  cord  and  the  sac  are  identified. 


482 


OPERATIVE    SURGERY 


The  structures  beneath  the  cord  are  incised  while  the  cord  and  sac  are  lifted 
up,  taking  care  to  make  the  incision  in  a  bloodless  area.  These  structures  are 
further  divided  with  scissors  so  that  the  cord  and  sac  together  are  separated 
from  the  inguinal  canal,  except  at  the  internal  ring.  A  piece  of  gauze  is 
carried  beneath  the  cord  and  sac.  The  sac  is  identified  and  dissected  free 
from  the  cord.  This  is  usually  best  done  by  incising  it  and  stripping  it  away 
from  the  tissues  while  the  finger  is  inserted  to  identify  and  stabilize  it 
(Fig.  460).  Often  the  structures  over  the  incised  sac  can  be  seized  with 
hemostatic  forceps  and  pulled  aAvay,  or  else  they  can  be  brushed  away  with 


Fig.  ,459. — The    inguinal    canal    is    exposed    by    splitting   the   fibers    of    the    external    oblique.      Note    the    ilio- 
hypogastric   nerve,    which    should    be    protected. 

dry  gauze.  It  is  dissected  free  from  all  structures  well  up  into  the  abdomen 
and  made  tense  by  traction  while  a  ligature  of  tanned  or  chromic  catgut  in 
a  needle  transfixes  its  neck  as  high  up  as  possible.  The  ligature  is  tied  by 
an  assistant  while  the  surgeon  holds  his  finger  in  the  sac  down  to  the  ligature 
to  prevent  a  knuckle  of  bowel  or  a  piece  of  omentum  being  caught  in  the 
ligature  (Fig.  461).  The  sac  is  cut  away  half  an  inch  from  the  ligature 
and  the  ligature  is  cut  short  when  the  neck  of  the  sac,  if  it  has  been 
properly  dissected  from  the  surrounding  tissues,  will  retract  within  the  ab- 
domen behind  the  cord  and  practically  out  of  sight.  (Fig.  462.)  Four 
or  five  interrupted  sutures  of  tanned  or  chromic  catgut  or  kangaroo  ten- 
don  approximate   the    internal   oblique    and    transversalis   muscles    and   the 


HERNIA 


483 


conjoined  tendon  above  to  the  slielvino-  edge  of  Poupart's  ligament  below.  The 
sutures  are  inserted  from  above  downward,  care  being  taken  to  avoid  the  in- 
clusion A\ilhin  the  sutures  of  the  ilioinguinal  or  the  ilioh^ypogastric  nerves. 
The  first  suture  is  placed  close  to  the  cord  as  it  emerges  from  the  internal 
inguinal  ring.  This  suture  is  inserted  while  the  cord  is  so  held  that  the  por- 
tion emerging  from  tlie  ring  is  perpendicular  to  the  body.  The  suture  catches 
a  good  bite  of  the  internal  oblique  and  transversalis  muscle  in  such  a  way 
that  when  carried  across  to  the  shelving  edges  of  Poupart's  ligament,  the 
suture  is  snngly  in  contact  with  the  cord.     In  this  Avay  just  enough  play  is 


The   sac   is  being  freed. 


left  for  the  emergence  of  the  cord  through  the  internal  ring  without  con- 
stricting it  too  greatly.  This  suture  is  tied  just  tightly  enough  to  secure 
satisfactory  approximation.  It  is  best  to  tie  three  knots.  If  tied  too  tightly 
necrosis  results  and  there  may  be  recurrence  of  the  hernia.  If  not  tied  suffi- 
ciently tightly  the  union  will  not  be  firm.  Three  or  four  sutures  are  placed 
below  this  at  intervals  of  about  one-half  an  inch.  The  last  suture  of  this  row 
catches  in  addition  to  the  conjoined  tendon  a  small  bite  in  the  under  surface 
of  the  aponeurosis  of  the  external  oblique  as  it  is  reflected  inward  by  retrac- 
tion (Fig.  463).  Care  must  again  be  observed  to  avoid  the  iliohypogastric 
nerve  which  enters  the  aponeurosis  of  the  external  oblique  near  this  point. 
This  suture,  which  like  the  others  that  have  been  inserted,  is  carried  under 
the  cord,  catches  the  edge  of  Poupart's  ligament  near  the  pubic  spine.     Coley 


484 


OPERATIVE   SURGERY 


has  called  attention  to  the  advisability  of  inserting  this  last  suture  in  the 
manner  described,  as  it  adds  materially  to  the  strength  of  the  abdominal 
wall  in  this  region.  Coley  also  places  one  or  two  sutures  external  to  the  in- 
ternal ring,  uniting  the  internal  oblique  to  Poupart's  ligament. 

The  cord  is  allowed  to  lie  upon  this  row  of  sutures  and  the  aponeu- 
rosis of  the  external  oblique,  which  was  split  at  an  early  stage  in  the  opera- 
tion, is  united  by  a  continuous  lock  stitch  of  tanned  catgut  (Fig.  464).  The 
vessels  which  have  been  clamped  are  tied  and  the  skin  wound  is  united  in  the 
usual  manner.    I  have  found  that  a  continuous  mattress  suture  of  fine  tanned 


Fig.   461. — The   neck   of   the   sac   is   ligated. 

catgut  is  very  satisfactory  for  suturing  the  skin  in  this  region  (Fig.  465). 
The  Avound  is  dressed  with  an  abundance  of  gauze  and  cotton  and  a  firm 
spica  bandage  is  applied.  This  operation  is  an  exceedingly  satisfactory  one 
and  in  indirect  inguinal  heniia  will,  if  properly  carried  out,  result  in  the  per- 
manent cure  of  more  than  ninety-five  per  cent  of  the  patients. 

In  some  instances,  particularly  when  a  local  anesthetic  is  used,  the  type 
of  operation  that  has  been  described  by  Ferguson  or  by  Andrews  is  easier 
and  gives  satisfaction,  though  the  results  in  indirect  hernia  are  not  supe- 
rior to  those  obtained  by  the  Bassini  operation  and  in  direct  hernia  the 
results  are  not  so  good. 

In  dissection  around  the  sac  very  frequently  a  considerable  deposit  of 


HERNIA 


485 


fat  is  foiiiul.  This  fat  yoiiu'tiiiu's  is  so  marked  and  so  eireiunscribed  as  to 
be  praetically  a  li])oma  and  it  may  extend  from  the  proi^eritoneal  fat  along 
the  cord  or  from  between  the  abdominal  muscles.  It  is  possible  that  such 
deposits  have  an  etiologic  relation  to  the  hernia.  At  anj-  rate  they  should 
be  dissected  free  so  that  the  cord  can  be  closed  in  snugly  at  the  internal  ring. 
]\rany  operators  follow  the  suggestion  of  Coley  and  place  a  suture  external  to 
the  cord  as  well  as  one  below  it  so  that  the  cord  emerges  between  the  two 
sutures.  If  there  seems  to  be  a  marked  deticiency  in  the  origin  of  the  internal 
oblique  and  transversalis  muscle  in  Poupart's  ligament,  as  Ferguson  has  noted, 
sutures  to  correct  this  deficiency  must  always  be  placed.     The  testicles  are  sup- 


Fig.  46. 


-The   cord   is   mobilized. 


ported  by  a  broad  strip  of  adhesive  which  runs  from  one  thigh  to  another 
and  permits  the  testicles  to  lie  on  this  adhesive  as  on  a  shelf. 

The  operation  of  E.  Wyllys  Andrews  involves  the  principle  of  imbri- 
cation and  in  indirect  hernia  with  a  strong  conjoined  tendon  the  method  is 
very  satisfactory.  It  is  also  desirable  in  operations  under  local  anesthesia, 
for  it  avoids  handling  the  cord  and  dissection  of  the  structures  beneath  the 
ccrd  which  sometimes  even  after  blocking  the  ilioinguinal  and  iliohypogastric 
nerves  cause  some  discomfort.  In  the  Andrews  operation  the  incision  is  made 
similar  to  the  Bassini  operation,  that  is,  half  an  inch  above  and  parallel 
to  Poupart's  ligament  and  extending  four  or  five  inches  outward  from  the 
external  inguinal  ring.     The  external  oblique  is  split  from  above  downward 


486 


OPERATIVE   SURGERY 


as  though  the  operation  Avere  to  he  done  under  local  anesthesia.  This  is 
an  excellent  rule  in  any  liernia  operation.  xVfter  splitting  tlie  fil)ors  of 
the  aponeurosis  of  the  external  oblique  through  the  external  ring,  tlie  apon- 
eurosis is  dissected  up  en  each  side  until  Poupart's  ligament  is  well  exposed 
below  and  the  conjoined  tendon  and  about  one  and  a  half  inches  of  the  internal 
oblique  and  transversalis  muscles  are  uncovered  under  the  upper  portion 
of  the  wound.  Xo  veins,  fascia  or  portions  of  the  eremaster  muscle 
are  removed.  The  sac  is  freed  and  excised  as  in  the  Bassini  operation. 
If  the  sac  is  large  the  part  that  lies  in  the  scrotum  is  not  always  re- 
moved, but  that  portion  in  the  inguinal  canal  is  resected.  In  a  large  hernia 
when  the  sac  is   completely  dissected  Andrews   sometimes  folds  up  the   sac 


Fig.  463. — The  conjoined  tendon  and  the  internal  oblique  and  transversalis  muscles  are  sutured  to 
Poupart's  ligament  beneath  the  cord.  Note  that  the  inner  suture  catches  in  addition  a  portion  of  the 
under   surface  of  the  aponeurosis   of  the   external   oblique. 

by  suturing  it  according  to  the  method  of  Macewen.  From  two  to  five 
sutures  of  chromic  catgut  unite  the  conjoined  tendon  and  the  internal  oblique 
and  transversalis  muscles,  together  with  the  edge  of  the  aponeurosis  of  the 
external  oblique  just  above  them,  to  the  shelving  edge  of  Poupart's  ligament 
over  the  cord.  This  leaves  a  flap  consisting  of  the  outer  portion  of  the  apo- 
neurosis of  the  external  oblique  Avhich  has  been  previously  split.  This  flap 
is  then  folded  over  the  roAv  of  sutures  and  fastened  to  the  aponeurosis  of  the 
external  obliciue  bj^  a  continuous  lock  stitch  of  chromic  or  tanned  catgut. 
AndrcAvs  finds  that  in  direct  hernias  the  overlapping  should  be  done  by  placing 
the  first  row  of  sutures  beneath  the  cord  so  the  sutures  unite  the  conjoined  ten- 


HERNIA 


487 


don  and  tlie  upper  edg-e  of  the  split  aponeurosis  of  the  external  oblique  to 
the  shelving  edge  of  Poupart's  ligament  beneath  the  cord.  The  lower  flap 
of  the  aponeurosis  is  then  folded  over  the  cord  and  fastened  in  such  a  manner 
that  the  cord  lies  in  a  new  canal.  The  skin  is  closed  in  the  usual  way.  This 
operation  has  much  to  commend  it  in  small  indirect  hernias  that  are  done 
under  local  anesthesia,  hut  it  is  sometimes  followed,  particularly  in  mus- 
cular individuals,  by  a  sensation  of  drawing  or  tightening  that  may  last  for 
months  after  the  operation. 

In  any  operation  involving  the  transplantation  of  the  cord,  as  in  the  Bas- 
sini  operation,  the  cremaster  muscle  which  is  intimately  associated  with  the 


Fig.   464. — The  incision  in  the  aponeurosis   of   the   external   oblique   is   closed   with   a   continuous   lock   stitch. 


transversalis  fascia  should  be  preserved  by  splitting  it  for  the  whole  length 
of  the  cord  from  the  internal  to  the  external  ring  and  shoving  it  behind  the 
cord.  In  this  w^ay  it  will  lie  behind  the  internal  row  of  sutures  and  act  as 
a  slight  support  against  the  intraabdominal  pressure. 

Ferguson  has  found  that  many  recurrences  are  due  to  a  deficient  origin 
of  the  internal  oblique  and  transversalis  muscles  from  the  outer  portion  of 
Poupart's  ligament.  Consequently,  after  the  sac  had  been  removed  in  the 
usual  way,  he  united  the  transversalis  fascia  by  a  continuous  suture  and  then 
sutured  the  internal  oblique  and  transversalis  to  Poupart's  ligament  from 
the  outer  portion  of  the  wound  down  to  the  inner  portion,  merely  leaving 
a  .sufficient  opening  at  the  external  ring  for  the   cord.     The  split  edges  of 


488 


OPERATIVE    SURGERY 


Fig.  46S. — The  skin  is  closed  with  a  continuous  mattress   suture  of  fine  tanned  catgut. 


Fig.  466.— A  flap  is  formed  from  the  sheath  of  the  rectus  muscle,  according  to  the  method  of  Halsted,  as  an 
additional  support  in  direct  inguinal  hernia. 


HERNIA 


489 


the  aponeurosis  of  the  external  ()l)li(iue  are  united  in  the  usual  "way.  The 
cord  is  not  disturl)e(l.  l)ut  merely  pushed  doAvn.  Ferguson  recommended  a 
curved  incision,  which  seems  unnecessary. 

The  most  unsatisfactory  type  of  inguinal  hernia  to  deal  with  is  a  direct 
liernia  or  else  a  combined  direct  and  indirect  in  whieli  there  is  a  double  sac, 
one  protruding  to  the  inner  and  the  other  to  the  outer  side  of  the  deep  epi- 
gastric vessels.  The  difficulty  in  curing  a  direct  inguinal  hernia  is  be- 
cause this  hernia  is  due  to  a  defect  in  the  conjoined  tendon.  This  defect 
may  consist  in  an  abnormally  weak  conjoined  tendon  or  the  tendon  may  be 
apparently  entirely  lacking,   and  there  is  nothing  to   support  this  weak  re- 


Fig.   467. — In   addition   to   the   flap   from   the   sheath    of   the    rectus   muscle,   the   fibers    of   the    rectus    muscle 
can   also   be   transplanted   according   to    the    suggestion    of    Bloodgood. 

giou  in  the  inguinal  canal,  whereas  in  indirect  hernia  Avith  a  strong  conjoined 
tendon  that  is  almost  normally  inserted  the  inner  part  of  the  wound  can 
be  readily  fortified.  Several  suggestions  have  been  made  concerning  the 
best  method  of  strengthening  this  Aveak  spot  in  the  inguinal  canal.  Blood- 
good  has  practiced  transplantation  of  the  rectus  muscle  by  splitting  the 
sheath  of  the  rectus  and  suturing  the  muscle  instead  of  the  conjoined  tendon 
to  Poupart's  ligament.  Halsted  makes  a  flap  of  fascia  from  the  sheath  of 
the  rectus  with  the  base  or  hinge  outward.  This  flap  is  sutured  under  the 
cord,  replacing  the  conjoined  tendon  (Fig.  466).  In  addition  to  this  flap 
the  rectus  muscle  can  also  be  sutured  to  Poupart's  ligament,  which  makes 


490 


OPERATIVE    SURGERY 


a  double  reinforcement  (Fig.  467).  It  has  been  objected  that  the  rectus 
muscle  alone  will  not  hold  satisfactorily  but  by  splitting  its  sheath,  form- 
ing a  flap,  and  suturing  this  under  the  cord,  and  then  suturing  the  rec- 
tus muscle  under  the  cord  just  over  the  flap,  the  rectus  will  be  more  likely 
to  maintain  its  position.  Even  if  it  does  not,  the  fascia  formed  from  the 
flap  of  the  rectus  sheath  will  probably  be  sufficient  reinforcement.  In  direct 
hernia  and  in  indirect  hernia  in  which  the  conjoined  tendon  appears  weak,  this 
modification  should  be  done.  In  direct  hernia  it  is  important  to  suture  the 
transversalis  fascia  together  over  the  stump  of  the  sac. 

There  are  a  number  of  different  operations  for  hernia.     The  most  satis- 


Fig.  468. — Exposure  of  the  neck  of  the  sac  from 

within  the  peritoneal  cavity.     (Method  of  G.  P. 

LaRoque.) 


Fig.   469. — Suturing  the   neck   of   the   sac   from 
within   the  peritoneal   cavity.      (LaRoque.) 


factory  operation  in  my  hands  has  been  the  operation  of  Bas.sini,  as  has  been 
described,  combined  Avith  the  Halsted-Bloodgood  modification  of  transplanta- 
tion of  a  flap  from  the  sheath  of  the  rectus  muscle  and  of  the  rectus  muscle 
itself  where  the  conjoined  tendon  is  very  weak.  In  cases  where  the  in- 
ternal ring  is  the  only  structure  at  fault  and  Avhere  a  local  anesthetic  is 
to  be  used,  the  Andrews  or  Ferguson  operation  is  very  satisfactory,  but 
the  Bassini  with  some  modification  can  be  used  in  almost  every  form  of  in- 
guinal hernia,  either  direct  or  indirect,  with  excellent  results.  In  any  type 
of  operation  the  cord  should  be  handled  gently  and  no  veins  or  other  struc- 
tures except  fat  should  be  removed  from  the  cord. 


HERNIA  491 

The  treatment  of  the  sac  of  either  inouinal  or  femoral  liernia  is  an  im- 
portant step  in  the  operation.  It  has  been  objected  that  tying  the  sac  at  its 
neck  ^\■ill  Jraxc  a  (iinij)h'  wilhiii  Ihc  ])eritoneal  cavity,  Avhich  invites  a  re- 
currence of  the  liernia.  To  obviate  this  it  is  always  necessary  to  dissect  the 
sac  well  nj)  beneatli  the  abdominal  muscles,  to  make  moderate  traction  upon 
it.  and  1(1  i>lace  the  ligature  flush  with  the  level  of  the  external  portion  of 
the  peritoneal  surface.  Preferably  the  ligature  should  transfix  the  neck  of 
the  sac.  This  method  of  ligating  is  important  in  any  type  of  operation  for 
hernia.  Even  such  a  ligature,  however,  has  been  objected  to  because  in 
sacs  with  large  necks  a  dimple  may  still  be  left.  The  Macewen  method  has 
apparent  advantages,  but  they  are  more  apparent  than  real.  The  technic 
of  Macewen 's  treatment  of  the  sac  is  as  follows:  After  partly  freeing  the 
sac  from  the  cord  the  surgeon  introduces  his  finger  into  the  inguinal  canal 
and  bluntly  dissects  the  sac  from  the  cord  and  from  the  walls  of  the  inguinal 
canal  and  the  surrounding  tissues.  He  then  carries  his  finger  through  the 
internal  ring,  separating  the  peritoneum  from  the  abdominal  wall  for  an 
inch  around  the  internal  ring.  A  chromic  or  tanned  catgut  suture  is  intro- 
duced at  the  lowest  portion  of  the  sac  and  quilted  through  the  sac  several 
times  toward  its  neck  so  that  pulling  upon  the  suture  will  draAV  the  sac  up 
into  a  lump.  The  needle  with  the  end  of  the  suture  that  has  come  out 
at  the  neck  of  the  sac  is  then  carried  through  the  internal  ring  and  trans- 
fixes the  abdominal  muscles  an  inch  above  the  internal  ring,  while  the  skin 
is  retracted  to  avoid  puncturing  it.  The  suture  is  pulled  snugly  and  folds  up 
the  sac  under  the  abdominal  muscles  so  that  it  lies  between  the  peritoneum 
and  the  inner  surface  of  the  abdominal  muscles.  This  suture  is  permanently 
anchored,  whipping  it  several  times  through  the  external  oblique.  For- 
merly this  method  of  treating  the  sac  was  considerably  in  vogue,  but  it 
does  not  of  necessity  avoid  the  dimpling  that  has  been  objected  to  and  it 
may  form  an  uneven  surface  at  a  naturally  well  protected  point  which  Avill 
increase  the  force  of  the  intraabdominal  pressure  further  down  on  the 
inguinal  canal.  In  a  sac  with  a  very  broad  neck  a  satisfactory  treatment 
is  to  close  the  neck  of  the  sac  flush  with  the  peritoneum  with  a  continuous 
purse-string  suture,  just  as  though  an  incision  had  been  made  through  the 
peritoneum  in  performing  an  abdominal  section.  The  treatment  of  the  sac 
cannot  be  entirely  standardized  by  one  method,  because  the  character  and 
shape  of  the  sac  may  alter  greatly. 

LaRoque,^  of  Richmond,  has  presented  the  problem  of  treating  the  sac 
of  either  inguinal  or  femoral  hernias  in  an  excellent  manner.  When  it 
is  difficult  to  excise  the  sac  and  when  it  is  thin  and  small  he  incises  the  peri- 
toneum above  the  neck  of  the  sac,  either  by  strongly  retracting  the  inter- 
nal oblique  and  transversalis  muscles,  or  by  splitting  these  muscles  in  the 
direction  of  their  fibers.  The  internal  opening  of  the  sac  is  exposed  by 
traction  upon  the  lower  margin  of  the  peritoneal  wound  with  a  hemostatic  for- 
ceps, together  with  retraction  of  the  upper  margin  (Fig.  468).     The  orifice 


^Surg.,  Gynec.  &  Obst.,  TCov.,   1919,  p.  SC7,   et    seq. 


492 


OPERATIVE    ST'RGERY 


Fig.  470. — Method  of  inverting  a  large  sac  from   within  the  peritoneal   cavity.      (LaRoque.) 


Fig.  471. — Suturing  the  neck  of  a  large  sac  from  within  the  peritoneal  cavity.      (LaRoque.) 


HERNIA  493 

of  the  sac  is  thou  "wliipped  over  Avitli  ;i  eoiitiiiiious  catgut  suture  and  the  re- 
dundant peritoncniiu  is  folded  over  the  sutured  orifice  and  takes  up  the  slack 
in  the  peritoneum  in  this  region,  preventing  the  formation  of  a  dimple  (Fig. 
469).  Where  the  sac  is  large,  hoM'ever,  and  presents  too  bulky  a  mass  to  1)e 
enclosed  along  -witli  the  cord,  tlie  finger  is  inserted  into  it  from  the  peri- 
toneal opening  and  it  is  freed  from  the  spermatic  cord  and  the  surround- 
ing structures.  The  finger  is  then  withdrawn  and  a  hemostatic  or  pedi- 
cle forceps  is  inti'oduced  through  the  neck  of  the  sac  to  its  lowest  por- 
tion which  is  caught  and  pulled  up,  turning  it  inside  out  (Fig.  470).  It 
can  then  be  treated  by  suturing  the  upper  margin  of  the  wound  in  the 
peritoneum  to  the  base  of  the  everted  sac,  after  bringing  it  up  through  the 
peritoneal  wound  (Fig.  471).  By  placing  the  sutures  an  inch  or  more  beyond 
the  neck  of  the  sac  all  redundant  peritoneum  in  the  neighborhood  of  the 
neck  is  put  on  a  stretch  and  the  peritoneal  opening  of  the  internal  ring  is 
completely  obliterated.  The  transversalis  fascia  which  is  inverted  with  the 
sac  is  included  in  the  peritoneal  suturing.  This  makes  most  of  the  sac  ex- 
traperitoneal. A  ligature  is  then  placed  around  it  if  it  is  large  and  the 
excess  is  amputated.  If  the  sac  is  small  it  is  not  necessary  to  excise  it. 
In  either  event  if  the  muscles  are  split  they  are  sutured  over  the  sac  or  its 
stump  and  the  rest  of  the  hernia  operation  is  done  according  to  some  of  the 
technics  that  have  already  been  described. 

FEMORAL  HERNIA 

Femoral  hernia  occurs  through  the  femoral  canal  and  is  most  frequently 
found  in  women.  It  is  peculiarly  liable  to  strangulation  because  of  the  com- 
paratively small  caliber  and  the  rigidity  of  the  femoral  canal.  A  number 
of  rather  complicated  operations  has  been  devised  though  the  simpler  meth- 
ods appear  to  be  quite  satisfactory.  In  the  radical  cure  of  a  nonstrangulated 
femoral  hernia  high  excision  of  the  sac  together  with  obliteration  of  the  fem- 
oral canal  as  has  been  practiced  by  a  number  of  operators,  particularly  by 
Coley,  seems  to  give  excellent  results. 

The  incision  for  operation  on  fenroral  hernia  is  similar  to  that  for  in- 
guinal hernia,  though  it  is  made  closer  to  Poupart's  ligament,  being  paral- 
lel to  Poupart's  ligament  and  just  above  it.  The  aponeurosis  of  the  ex- 
ternal oblique  is  exposed  and  the  lower  margin  of  the  wound  retracted  to 
uncover  the  sac.  Some  operators  prefer  a  vertical  incision,  beginning  about 
an  inch  above  Poupart's  ligament  and  going  downward  on  the  thigh.  This  is 
objectionable  because  it  leaves  a  scar  that  runs  transversely  to  the  creases  in 
the  groin  and  may  cause  discomfort.  Then,  too,  when  ligation  of  the  sac  high 
up  in  the  femoral  canal  is  difficult  the  peritoneum  can  be  opened  and  the  sac 
inverted  according  to  the  method  of  LaRoque. 

After  exposing  the  neck  of  the  sac  its  body  is  separated  from  the 
surrounding  tissues.  The  sac  of  a  femoral  hernia  is  always  thickly  cov- 
ered with  fat,  which  is  uncommon  in  inguinal  hernia,  except  in  direct  in- 


494  OPERATIVE    SURGERY 

guinal  hernia  where  the  sac  is  near  the  bladder.  The  sac  of  a  femoral  hernia 
is  usually  easily  separated  from  the  surrounding  tissue.  Its  neck,  together 
M'ith  the  attaclied  fat,  is  dissected  well  up  into  the  femoral  canal  while 
the  roof  of  the  femoral  canal  is  strongly  retracted  with  a  small  blunt  re- 
tractor. The  sac  is  opened  and  inspected.  If  there  is  adherent  omentum 
the  adhesions  are  separated  and  the  bleeding  parts  of  the  omentum  are  li- 
gated  with  catgut  and  the  omentum  is  returned.  If  the  omentum  is  thick  and 
contains  much  scar  tissue  it  should  be  pulled  down  until  healthy  omentum 
is  reached  and  at  this  point  is  ligated  in  small  sections  and  the  distal 
portion  removed.  It  is  best  to  protect  the  raw  surface  of  the  omentum 
by  whipping  over  it  the  adjoining  healthy  omentum.  Sometimes,  however, 
this  may  make  too  large  a  bulk  to  permit  reduction  of  the  mass  through  the 
femoral  canal.  To  facilitate  reduction  it  may  be  necessary  to  ligate  and  divide 
the  omentum  at  different  levels,  but  care  must  be  taken  to  see  that  there  is 
no  severed  vessel  between  the  ligatures.  The  omentum  should  never  be  re- 
turned to  the  peritoneal  cavity  until  it  is  certain  that  bleeding  from  the 
stump  has  been  entirely  and  satisfactorily  controlled. 

Having  dealt  with  the  contents  of  the  sac  if  there  are  any,  the  neck 
is  transfixed  with  tanned  or  chromic  catgut  in  a  needle,  firmly  tied,  and 
the  sac  is  cut  away,  leaving  a  stump  about  one-third  of  an  inch  long  so  there 
will  be  no  possibility  of  the  ligature  slipping.  The  stump  should  then  retract 
well  within  the  femoral  canal.  It  is  important  to  see  that  the  neck  of  the  sac 
is  thoroughly  separated  high  up  into  the  femoral  canal  before  it  is  ligated 
and  if  this  is  done  the  stump  will  retract  so  it  will  be  practically  out 
of  sight.  The  femoral  canal  is  obliterated  by  a  suture  of  tanned  or  chro- 
mic catgut  in  a  curved  needle.  This  begins  over  the  inner  portion  of  the 
roof  of  the  femoral  canal  through  Poupart's  ligament.  The  margin  of  the 
femoral  canal  is  strongly  retracted  upward  by  a  small  blunt  retractor  and 
a  second  bite  is  taken  in  the  pectineus  muscle  and  the  fascia  along  the 
inner  portion  of  the  floor  of  the  femoral  canal.  This  is  near  the  origin  of 
the  muscle  from  the  pubic  bone.  The  suture  is  then  carried  to  the  outer  wall 
of  the  femoral  canal  and  a  bite  is  taken  in  the  tissues  and  fascia  in  this  neigh- 
borhood, taking  care  not  to  injure  the  femoral  vein.  Catching  a  small  piece 
of  the  fascia  to  the  inner  side  of  the  sheath  of  the  femoral  vein  affords  a 
strong  hold.  The  needle  is  then  carried  through  the  roof  of  the  femoral 
canal,  penetrating  Poupart's  ligament,  but  at  a  point  lower  down  than  the 
beginning  of  the  suture  so  that  a  sufficient  amount  of  the  fibers  of  Poupart's 
ligament  lies  betAveen  the  levels  of  the  beginning  and  the  ending  of  the 
suture  in  order  not  to  split  Poupart's  ligament.  The  suture  when  snugly 
tied  obliterates  the  femoral  canal.  The  skin  is  closed  in  the  usual  manner. 
A  dressing  with  a  spica  bandage  is  applied  to  maintain  firm  pressure  on 
the  wound  and  to  prevent  an  accumulation  of  serum  in  the  space  from  which 
the  sac  was  dissected. 

The  so-called  sliding  hernia  has  been  mentioned.  It  often  occurs  in  femoral 
hernia.     The  portion  of  the  intestine  uncovered  with  peritoneum  which  was 


HERNIA 


495 


formerly  tlion<>lit  to  he  a  sliding  or  eversion  of  tiie  mesentery,  bnt  is  now  known 
to  be  only  an  obliteration  of  the  peritoneum,  is  always  on  the  onter  side  of  the  sac. 
The  sae  shonld  be  earefully  dissected  on  all  sides,  except  where  it  is  attaelied  to 
the  large  bowel.  The  sac  is  split  at  the  farthest  point  from  the  large  bowel,  re- 
flected over  that  portion  of  bowel  which  is  uncovered  by  peritoneum,  and  held  in 
position  by  a  few  sutures.  The  vessels  of  the  bowel  are  carefully  protected  in  or- 
der not  to  impair  its  nutrition. 

An  operation  for  femoral  hernia  hy  attacking  the  sac  from  above  has 
been  proposed  by  Dujarier  and  also  by  M.  G.   Seelig  and  Tuholski.     This 


Fig'.  472. — Exposure  of  neck  of  the  sac  of  a  femoral  hernia  by  the  method  of   Seelig  and  Tuholski. 


method  has  many  obvious  advantages  and  should  always  be  used  in  strangu- 
lated or  incarcerated  femoral  hernia.  It  is  sometimes  difficult  in  a  strangulated 
hernia  to  be  certain  whether  the  hernia  is  femoral  or  inguinal  and  the  incis- 
ion for  femoral  hernia  should  under  all  conditions  be  parallel  to  Poupart's 
ligament  and  only  slightly  lower  than  the  incision  for  inguinal  hernia.  The 
incision  extends  down-ward  and  inward  somewhat  nearer  the  pubis  than  in 
inguinal  hernia,-  and  is  about  four  inches  in  length.     The  aponeurosis  of  the 


=Seelig  &  Tuholski:        Surg.,   Gynec.   &  Obst.,  Jan.,   1914,  p.   SS,   et    seq. 


496 


OPERATIVE    SURGERY 


external  oblique  is  divided  along  the  direction  of  its  fibers  as  in  ingninal 
hernia,  and  the  upper  flap  of  the  aponeurosis  together  with  the  conjoined 
tendon  is  retracted  upward  while  the  lower  flap  is  retracted  downward  to 
expose  the  inner  surface  of  Poupart's  ligament.  A  strip  of  gauze  or  tape 
may  be  placed  under  the  round  ligament  or  under  the  spermatic  cord  to  re- 
tract it  out  of  the  way.  This  exposes  the  transversalis  fascia  which  is  very 
thin  and  beneath  this  is  the  peritoneum  (Fig.  472).  The  deep  epigastric 
artery  is  retracted  externally  or  it  may  be  doubly  ligated  and  divided.     The 


Fig.   473. — The  neck  of   the  sac  is  ligated,  the  sac  excised,   and  sutures   are  placed   to  obliterate   the   femoral 

canal.      (Seelig  and   Tuholski.)  , 


transversalis  fascia  is  divided  and  caught  in  retractors  and  the  peritoneum 
near  the  neck  of  the  hernial  sac  is  brought  into  view.  The  peritoneum  is 
opened  just  above  the  neck  of  the  sac  and  the  hernial  contents  are  pulled  out 
of  the  sac.  This  may  be  aided  by  pressure  over  the  sac  with  one  hand  while 
the  contents  are  being  pulled  upon  with  the  fingers  of  the  other  hand  within 
the  abdomen.  If  there  is  strangulation  the  constriction  is  overcome  by  cut- 
ting the  inner  margin  of  the  femoral  ring,  which  constitutes  Gimbernat's 
ligament.  This  is  much  more  easily  repaired  than  the  usual  method  of  cut- 
ting forward  which  divides  transversely  the  important  fibers  of  Poupart's 


HERNIA  497 

ligament  and  makes  subsequent  repair  difficult.  This  incision  is  made  with 
blunt-pointed  scissors  or  a  probe-pointod  knife.  Any  vessel  that  is  injured 
can  be  readily  exposed  and  clamped.  If  the  hernial  contents  are  adherent  to 
the  sac,  sometimes  with  traction  the  hernial  contents  together  with  the  sac, 
can  be  delivered  into  the  abdomen  through  the  wound,  the  sac  being  inverted. 
The  adhesions  are  readily  dealt  with.  If  the  sac  is  adherent  and  cannot  be 
delivered  in  this  manner  an  incision  may  be  made  directly  over  it,  though,  as  a 
rule,  retraction  of  the  skin  and  subcutaneous  fat  of  the  lower  margin  of  the 
wound  will  enable  the  sac  to  be  dealt  with  without  the  additional  incision.  If 
the  hernial  contents  have  been  reduced,  a  pair  of  hemostatic  forceps  is  inserted 
through  the  abdominal  wound  into  the  sac  to  its  bottom,  which  it  seizes  and 
inverts.  The  sac  is  closed  by  a  transfixion  ligature  of  catgut  in  such  a  manner 
that  the  stump  leaves  no  dimple  (Fig.  473).  It  is  also  possible  to  treat  the  sac  as 
recommended  by  LaKoque  in  inguinal  hernia.  The  femoral  ring  is  easily  closed 
as  it  is  fully  exposed  by  retraction.  The  horizontal  ramus  of  the  pubis  is  covered 
with  a  tough  fascia,  which  is  Cooper's  ligament.  A  suture  of  tanned  or  chromic 
catgut  in  a  small  full  curved  needle  is  passed  from  Cooper's  ligament  going 
down  to  the  periosteum  and  just  internal  to  the  iliac  vein  through  the  lower 
portion  of  the  transversalis  fascia  and  the  edge  of  Poupart's  ligament.  The 
other  sutures  are  placed  internal  to  this  one,  the  innermost  suture  picking 
up  Gimbernat's  ligament.  These  three  interrupted  sutures  effectively  close 
the  femoral  canal.  The  first  suture  is  placed  close  to  the  iliac  vein,  which  is 
retracted  with  a  blunt  retractor,  and  the  tissues  should  be  well  in  view  be- 
fore the  suture  is  placed  (Fig.  473).  A  few  interrupted  sutures  of  tanned  or 
chromic  catgut  now  approximate  the  conjoined  tendon  and  the  internal 
oblique  and  transversalis  muscles  to  Poupart's  ligament  without  transplant- 
ing the  cord,  or  the  round  ligament,  and  the  aponeurosis  of  the  external 
oblique  is  sutured  in  a  separate  layer  with  a  continuous  tanned  or  chromic 
catgut  ligature,  as  in  the  operation  of  Ferguson.  This  operation  of  Seelig, 
Avhich  is  an  elaboration  and  modification  of  the  operation  of  A.  V.  Mosch- 
eowitz,  and  of  Dujarier,  is  but  slightly  more  difficult  than  the  simple  opera- 
tion of  exposing  the  sac  from  below  Poupart's  ligament  and  obliterating  the 
femoral  canal  by  a  purse-string  suture  from  below.  In  strangulation  or  in 
incarcerated  hernia  an  operation  of  the  type  of  the  Seelig  should  always  be 
done  and  where  the  femoral  canal  is  large  this  operation  will  make  the  only 
satisfactory  closure. 

Occasionally  when  there  is  marked  distention  of  the  abdomen  and  the 
contents  of  the  strangulated  femoral  hernia  are  tense  it  may  be  difficult  by 
an  internal  incision  to  divide  the  femoral  canal  sufficiently  to  relax  the  con- 
striction and  deliver  the  intestines  within  the  abdominal  cavity.  Then,  too, 
when  the  bowel  is  apparently'  gangrenous  or  when  perforation  is  imminent  it 
may  be  wise  to  relieve  constriction  by  cutting  through  Poupart's  ligament 
from  without  inward  and  to  inspect  the  strangulated  hernial  contents  before  an 
attempt  is  made  at  replacement  within  the  abdomen.  In  such  instances  the 
aponeurosis  of  the  external  oblique  is  split  as  close  to  Poupart's  ligament 


498 


OPERATIVE   SURGERY 


^ 

^ 

^^^^p 

^^^«^^ 

y 

y 
y 

/^ 

/''C<&^^ 

A, . 

Fig.  474. — When  it  is  necessary  to  divide  Poupart's  ligament,  the  ligament  may  be  reconstructed  by  a 
flap  from  the  aponeurosis  of  the  external  oblique.  The  drawing  shows  the  lines  of  incision  for  such 
a  flap. 


Fig.   475. — The  flap   has  been   sutured  into   position  so   as   to   reinforce   Poupart's   ligament. 


HERNIA 


499 


as  possible  and  Poiipart's  ligament  is  divided  transversely.  This  should 
never  be  done  except  under  the  nniisiial  conditions  mentioned,  for  when 
Poiipart's  ligament  is  divided  in  this  manner  it  is  impossible  to  suture  it 
together  satisfactorily.  The  cut  ends  may  be  approximated  with  mattress 
stitches  Avhich  are  loosely  tied,  though  it  is  impossilde  to  bring  them  into 
contact  because  the  sutures  will  split  out.  The  internal  margin  of  the 
aponeurosis  of  the  external  oblique  can  be  divided  transversely  for  an  inch 
close  to  its  insertion  into  the  pulnc  bone  and  split  up  so  that  it  has  a  base 
externally  (Fig.  474).  This  flap  is  carried  to  the  region  of  the  divided 
Poupart's  ligament  and  fastened  securely  to  the  outer  and  inner  ends  of 
the  divided  ligament,  so  closing  the  gap  and  acting  as  a  splice  between 
the  two  divided  portions  of  Poupart's  ligament.  The  end  of  this  flap  should 
also  be  sutured  to  Cooper's  ligament  along  the  margin  of  the  pubic  bone. 
The  rest  of  the  aponeurosis  is  brought  down  over  part  of  its  extent  and  with 
the  conjoined  tendon  and  internal  oblique  and  transversalis  is  sutured  to  the 
reinforced  Poupart's  ligament  (Fig.  475).  I  was  compelled  to  sever  Pou- 
part's ligament  once  and  this  procedure  was  followed  by  satisfactory  results. 

UMBILICAL  HERNIA 

Umbilical  hernias  occur  most  frequently  in  fat  persons.  An  operation  that 
merely  approximates  the  edges  of  the  hernial  ring  after  removing  the  sac 
is  unsatisfactory.  The  technic  devised  by  the  Mayos  has  greatly  improved 
the  results  of  operations  upon  this  type  of  hernia  and  is  now  generally 
adopted.  The  principle  underlying  the  Mayos'  operation  is  that  of  over- 
lapping the  wound  from  above  downward.  Formerly,  when  attempts  were 
made  to  close  this  hernia  by  suturing  the  ring  from  side  to  side  many 
of  these  stout  patients  succumbed  to  edema  of  the  lungs  or  to  failure  of 
the  heart  because  an  extra  burden  was  placed  upon  the  lungs  and  heart  by 
the  constriction  resulting  from  the  longitudinal  suturing  of  the  hernial  ring. 
If,  however,  the  tissues  are  overlapped  from  above  downward  and  if  in 
the  after-treatment  the  patient's  thighs  are  elevated  and  a  pillow  is  placed 
under  the  shoulders  and  head,  there  is  comparatively  slight  discomfort. 
The  incision  is  transverse  and  is  made  in  an  elliptical  manner  to  surround 
the  umbilicus  and  the  hernia.  The  incision  should  be  generous  and  if  the 
patient  is  very  fat  a  considerable  amount  of  fat  is  included  with  the 
skin.  The  neck  of  the  hernia  is  exposed  and  the  aponeurosis  for  at  least 
an  inch  and  a  half  around  the  neck  is  dissected  free  of  fat  (Fig.  476). 
The  sac  is  divided  near  the  neck  by  an  incision  parallel  with  the  open- 
ing of  the  neck  and  the  hernial  contents  are  exposed.  The  adhesions  are  freed 
and  if  there  is  adherent  omentum  it  is  ligated  in  sections  and  removed  along 
with  the  sac.  Care  should  be  taken,  hoAvever,  to  inspect  the  contents  of  the 
hernia  from  the  opening  near  the  neck  of  the  sac  in  order  to  be  certain 
that  the  nutrition  of  the  bowel  is  not  interfered  with  before  ligating  what 
seems  to  be  merely  omentum;  for  mesentery  may  be  caught  in  the  sac  and 
may  appear  to  be  omentum.     The   edges   of  the  neck   of  the   sac   and  the 


500 


OPERATIVE    SURGERY 


Fig.   476. — The   neck    of   the    sac   of   an   umbilical    hernia   is   exposed   and   is   ready   for    incision. 


Fig.    477. — Mattress    sutures    for    imbrication    of    the    margins    of    the    opening    in    the    aponeurosis    of    the 

abdominal    wall   are   placed. 


HERNIA 


501 


margins  of  the  umbilical  ring  are  seized  with  forceps  as  the  incision  is  con- 
tinued around  the  neck  of  the  sac.  The  sac  should  not  be  cut  too  close  to 
the  neck  as  all  the  peritoneal  tissue  and  even  thin  fascia  which  can  be 
saved  add  to  the  strength  of  the  reconstructed  abdominal  wall.  The  intes- 
tinal contents  are  packed  off  with  moist  gauze.  Exposure  with  a  retractor 
should  be  ample  while  passing  the  sutures.  The  sutures  are  stout  tanned  or 
chromic  catgut.  The  first  suture  is  inserted  in  the  midline  about  two  inches 
below  the  lower  margin  of  the  umbilical  ring,  appears  in  the  abdominal 
cavity  and  is  carried  to  the  upper  margin  of  the  umbilical  ring  where  it 
takes  a  bite  in  the  peritoneum  and  fascia,  and  then  returning  is  passed 
from  the  peritoneal  cavity  outward  at.  a  point  about  one-half  an  inch 
to  one  side  of  the  point  of  entrance.     The  ends  are  cut  long  and  clamped 


>*      ^^' 


J^ 


■^-f    T  ^  \  "TxC^ 


Fig.    478. — The    mattress    sutures    have    been   tied   snugly   and   the   margin    of   the    overlapped    aponeurosis    is 
sutured    to    the    surface    of   the   aponeurosis   which    it    overlaps. 


but  not  tied.  One  or  more  sutures  are  similarly  passed  on  each  side  of  this 
central  suture.  The  number  of  sutures,  of  course,  depends  upon  the  size  of 
the  ring  (Fig.  477).  After  the  sutures  have  been  placed  they  are  all  grasped 
at  the  same  time  and  by  traction  the  upper  margin  of  the  ring  is  im- 
bricated under  the  lower  margin.  The  sutures  are  tied  one  at  a  time 
while  all  are  held  taut.  In  this  manner  no  undue  tension  is  placed  upon 
any  single  suture.  The  overlapping  is  ample  to  provide  for  a  considera- 
ble retraction  of  the  margins  without  a  recurrence  of  the  hernia.  A  con- 
tinuous lock  stitch  of  tanned  or  chromic  catgut  fixes  the  former  lower  margin 
of  the  ring  of  the  umbilical  hernia  to  the  aponeurosis  over  which  it  noAV  lies 
(Fig.  478).  The  skin  is  closed  in  the  usual  manner.  It  is  well  to  introduce 
a   small   drain   of   catgut   mat   or  folded  rubber   tissue   in  the    outer   angles 


502 


OPERATIVE   SURGERY 


of  the  wound  to  give  exit  to  the  broken  down  fat  that  not  infrequent!}^  occurs 
in  stout  people  after  this  operation. 

If  the  local  conditions  make  it  easier  to  carry  the  lower  margin  of 
the  umbilical  ring  under  the  upper  margin,  instead  of  the  reversed  procedure 
which  has  just  been  described,  this  can  be  done,  as  it  makes  no  essential  dif- 
ference in  results.  The  important  points  are  to  free  the  external  fascia  from 
fat,  to  introduce  the  first  mattress  suture  at  a  sufficient  distance  from  the 
margin  of  the  ring,  to  secure  ample  overlapping,  and  to  bring  all  sutures 
up  taut  before  any  suture  is  tied. 

INCISIONAL  OR  VENTRAL  HERNIA 

Incisional  or  ventral  hernias  follow  injury  to  the  abdominal  wall,  usu- 
ally an  operation,  and  are  prone  to  occur  after  infection  where  union,  is  poor 
or  in  stout  individuals  where  the  intraabdominal  pressure  is  great.  The  com- 
bination of  infection  and  fat  is  particularly  liable  to  develop  hernia.  As  in- 
fection plays  a  considerable  part  in  the  development  of  an  incisional  hernia, 
adhesions  of  the  viscera  to  the  sac  are  common.  The  explanation  of  the 
formation  of  these  adhesions  has  been  greatly  clarified  by  Hertzler,^  who 
has  shown  that  adhesions  are  dense  along  the  periphery  of  a  severe  infection 
and  not  in  its  center,  as  has  been  commonly  supposed.  Consequently,  after 
a  hernia  following  an  abdominal  infection  the  focus  of  the  beginning  of  in- 
fection may  be  found  free  from  adhesions  while  the  viscera  are  well  plastered 
to  each  other  or  to  the  peritoneum  at  some  distance  away.  It  is,  of  course, 
necessary  to  free  the  adhesions  from  the  sac  of  an  incisional  hernia  Avhen 
operating  to  cure  the  hernia.  While  all  adhesions  in  the  abdominal  cavity 
need  not  be  freed,  any  single  band  or  strong  points  of  adhesions  should  be 
cut  because  they  are  more  likely  than  broad  extensive  adhesions  to  cause 
obstruction. 

The  incision  is  so  made  as  to  include  the  scar  in  the  skin  from  the 
previous  operation.  The  peritoneal  cavity  is  opened  at  the  upper  or  the 
lower  end  of  the  incision,  making  an  effort  to  enter  just  above  or  just 
below  the  margins  of  the  hernia.  Usually  it  is  better  to  go  in  above,  because 
most  of  these  hernias  occur  in  the  midline  and  an  incision  below  may  involve 
the  bladder.  After  entering  the  abdominal  cavity  the  adhesions  are  freed, 
bluntly  if  possible,  and  the  incision  is  carried  down  through  the  midline, 
freeing  adhesions  as  the  incision  progresses.  The  sac  which  consists  of  peri- 
toneum and  thin  bands  of  fascia  is  split  down  the  middle.  AV.  J.  Mayo  has 
called  attention  to  the  great  value  of  jDeritoneum  in  oiierating  on  this  type  of 
hernias  and  the  sac  should  never  be  cut  away  but  should  be  preserved.  After 
the  adhesions  have  been  freed  the  skin  with  the  subcutaneous  fat  is  separated 
on  each  side  to  a  point  well  beyond  the  weakened  thin  wall  of  the  hernia. 
Often  the  margins  of  the  hernia  are  not  sharp  as  in  umbilical  hernia,  but 
gradually  merge  into   healthy  tissue.     The  margins   are   overlapped   as   de- 


^Hertzler,  A.  Tt.:     The  Peritoneum,  i,  p.  276,   et  seq. 


HERNIA  503 

scribed  in  umbilical  lioriiiu,  except  that  they  are  overlapped  from  side  to  side  in- 
stead of  from  above  downward.  The  first  mattress  suture  of  stout  tanned 
or  chromic  catgut  is  taken  preferably  on  the  right  side  about  one  and  a  half 
or  two  inches  from  the  apparent  margin  of  the  weak  hernial  tissue.  This 
may  be  a  distance  of  four  or  more  inches  from  the  edge  of  the  incision  in 
the  hernial  sac.  The  suture  is  carried  in  full  view  to  the  left  margin  of  the 
sac  and  after  catching  the  edge  of  the  sac  and  its  weak  fascia  a  second  bite 
with  the  needle  is  made  farther  back  from  the  edge,  taking  care  to  secure  at 
least  fairly  strong  tissue.  The  bite  should  not  go  far  enough  out  from  the 
edge  to  include  the  thick  healthy  abdominal  wall,  because  this  would  mean 
too  much  overlapping  and  too  great  strain  upon  the  tissues,  and,  consequently, 
too  much  intraabdominal  pressure  with  its  resulting  effect  upon  the  heart  and 
lungs.  This  suture  is  returned  in  a  reverse  direction  and  the  ends  are  left  long 
and  clamped.  After  a  series  of  these  mattress  sutures  have  been  inserted  care  is 
taken  to  remove  all  gauze  from  the  abdomen  that  may  have  been  placed  to  pro- 
tect the  viscera  while  passing  the  suture.  The  sutures  are  held  up  taut  while  the 
margin  of  the  left  portion  of  the  sac  is  slid  under  the  margin  of  the  right  half. 
These  sutures  are  tied  one  at  a  time  while  the  others  are  held  taut,  mak- 
ing three  or  four  ties  to  each  knot.  The  right  margin  of  the  sac,  which 
now  overlaps  considerable  tissue,  is  attached  to  the  fascia  on  the  left  side 
by  a  continuous  lock  stitch  of  tanned  catgut.  The  skin  is  closed  in  the  usual 
manner.  This  operation,  which  is  based  on  the  principles  enunciated  by 
W.  J.  Mayo  of  the  great  value  of  peritoneum  in  repair  of  this  type  of  hernias, 
is  much  better  than  the  anatomical  dissection  in  the  midline,  for  all  tissues 
are  saved,  no  possible  support  is  wasted,  and  the  double-breasted  effect  makes 
a  recurrence  improbable. 

Occasionally  a  hernia  occurs  after  a  drainage  operation  for  appendi- 
citis through  the  muscle  splitting  McBurney  incision.  If  the  patient  is 
kept  in  bed  sufficiently  long,  hernia  after  drainage  through  a  McBurney 
incision  is  rare,  and  when  it  does  occur  is  usually  not  large.  Occa- 
sionally, however,  the  tissue  yields.  Here  an  anatomical  dissection  is  pref- 
erable to  the  overlapping  method,  because  the  wound  is  closed  in  layers  and 
in  the  different  planes  of  closure  the  lines  of  sutures  are  not  parallel  as  in 
an  anatomical  dissection  of  a  ventral  hernia  in  the  midline  of  the  abdomen. 
In  a  ventral  or  incisional  hernia  following  a  McBurney  incision  the  scar  in 
the  skin  is  excised  so  that  only  healthy  skin  is  brought  together  when  the 
wound  is  closed.  This  principle  should  be  followed  so  far  as  possible  in 
any  secondary  operation.  The  fascia  of  the  external  oblique  is  recognized  in 
either  the  lower  or  the  upper  portions  of  the  wound  and  is  split  a  short  dis- 
tance from  the  margin  of  the  hernia.  The  split  edges  of  the  aponeurosis  of  the 
external  oblique  are  dissected  up  on  each  side,  freeing  them  for  some  distance 
from  the  margins  of  the  hernia  and  trimming  away  any  irregular  adhesions  or 
masses  of  scar  tissue.  Under  strong  retraction  the  internal  oblique  and  transver- 
salis  muscles  are  exposed  and  dissected  free.  The  sac  is  then  opened  near  its 
neck  as  in  umbilical  hernia.    The  adhesions  are  freed  and  damaged  omentum 


504 


OPERATIVE    SURGERY 


is  ligated  in  sections  and  divided,  removing  the  adlierent  omentum  with  the 
sac.  The  peritoneum  is  closed  with  a  continuous  mattress  suture  of  cat- 
gut, and  the  margins  of  the  internal  oblique  and  transversalis  muscle,  which  have 
been  thoroughly  mobilized,  are  brought  together  with  sutures  of  plain  or 
tanned  catgut.  The  mobilization  should  be  so  complete  that  there  Avill  be  no 
tension  upon  the  sutures.  The  aponeurosis  of  the  external  oblique  is  sutured 
with  a  continuous  lock  stitch  of  plain  catgut.  The  skin  is  closed  in  the  usual 
manner. 

EPIGASTRIC  HERNIA 

Epigastric  hernia  has  been  occasionally  discussed  in  medical  journals 
since  Terrier's  publications  described  this  condition  and  his  operations  for 
its  cure  in  1885.  It  seems,  however,  to  have  attracted  but  little  attention.  Not 
infrequently  small  epigastric  hernias  are  diagnosticated  and  treated  as  ulcer 


Fig.    479. — An   eiaigastric   hernia   is    exposed.      It   shows    the   protrusion    of   the   subperitoneal    fat    through    a 
defect  in  the  aponeurosis  in  the  midline  of  the  epigastric  region. 

of  the  stomach  or  gall  bladder  disease.  Epigastric  hernia  is  situated  in  the 
anterior  abdominal  Avail  in  or  very  near  the  linea  alba  between  the  umbilicus 
and  the  ensiform  cartilage.  It  may  occur  in  the  linea  semilunaris  or  some- 
times in  the  lineae  transversse  of  the  rectus  muscle.  It  varies  in  size  from 
a  small  protrusion  not  more  than  a  fourth  of  an  inch  in  diameter  which 
contains   only  properitoneal   fat,   to   a   large   mass   several   inches   in   diam- 


HERNIA  505 

eter.  The  diagnosis  of  a  large  mass  is  obvious,  but  a  small  epigastric 
liernia  with  but  slight  protrusion  and  containing  only  properitoneal  fat  is 
sometimes  easy  to  overlook.  They  are  not  infrequently  multiple  and  this 
fact  should  be  borne  in  mind  when  operating  for  this  condition.  The  defect 
is  usuall}^  congenital  but  when  the  hernia  occurs  in  the  linea  semilunaris  or 
in  a  transverse  line  of  the  rectus  muscle  it  may  follow  an  enlargement  of 
the  perforation  of  the  blood  vessels.  In  the  midline  a  congenital  defect  such 
as  is  the  cause  of  most  hernias  is  the  probable  explanation  for  this  hernia. 
The  patient  himself  may  discover  a  small  lump  no  larger  than  the  tip  of  the 
finger,  which  is  painful  and  tender  while  he  stands  or  sits,  but  disap- 
pears along  with  the  symptoms  when  he  lies  down.  Such  symptoms  are 
exceedingly  suggestive  of  epigastric  hernia.  In  very  fat  individuals  it  is 
sometimes  difficult  to  feel  the  hernia  even  when  the  patient  is  standing. 

An  incision  should  be  carefully  made  in  the  midline  and  carried  down  to  the 
fascia  before  the  fascia  is  divided.  The  fat  is  stripped  away  from  the  fascia 
for  a  distance  of  two  inches  on  each  side  and  the  midline  and  the  sheath  of 
both  muscles  are  fully  inspected.  If  the  opening  is  small  it  merely  amounts  to 
a  protrusion  of  some  properitoneal  fat.  This  properitoneal  tissue  is  well 
supplied  with  sensory  nerves  and  when  the  intraabdominal  pressure  forces  it 
through  a  small  aperture  pain  is  produced,  which  may  be  relieved  when  the 
patient  lies  down  and  the  fat  falls  back  into  its  normal  place.  An  epigastric 
hernia  with  a  large  peritoneal  sac  usually  gives  but  little  discomfort  unless 
there  are  adhesions  or  strangulation  (Fig.  479).  If  the  hernia  consists  merely 
of  properitoneal  fat  there  is  no  occasion  for  opening  the  abdominal  cavity, 
but  the  fascia  is  split  in  the  midline  both  above  and  below  the  hernia  and 
overlapped  for  a  distance  of  about  half  an  inch,  inserting  two  or  more  mat- 
tress sutures  of  tanned  or  chromic  catgut  in  order  to  hold  one  edge  of  the  fascia 
under  the  other  and  fastening  the  superficial  edge  to  the  fascia  beneath  it 
with  a  continuous  lock  stitch  of  tanned  or  chromic  catgut.  If  the  hernia  is 
a  large  one  and  contains  a  well  formed  peritoneal  sac,  the  sac  is  removed,  leav- 
ing a  sufficient  margin  of  peritoneum  in  which  to  apply  a  continuous  mattress 
suture  without  too  much  tension.  The  edges  of  the  fascia  are  then  overlapped, 
as  has  been  described.  The  overlapping,  however,  should  not  be  more  than  an 
inch,  as  more  than  this  will  produce  too  great  intraabdominal  pressure  in  this 
region  and  may  embarrass  respiration.  As  the  sac  in  such  a  hernia  does  not 
contain  elements  of  fascia  as  in  an  incisional  hernia  it  had  Ijest  be  treated 
by  excision  of  the  sac  instead  of  the  overlapping  described  in  operation 
on  incisional  hernia. 

DIAPHRAGMATIC   HERNIA 

This  condition  is  one  of  the  many  diseases  in  which  x-ray  has  greatly 
aided  the  diagnosis.  While,  as  Balfour  says,  it  is  not  exceedingly  rare  it  is 
uncommon.  Diaphragmatic  hernia  may  be  purely  traumatic,  as  from  a  stab 
wound,  or  a  gun  shot  injury  which  involves  the  diaphragm;  or  it  may  be  the 


506  OPERATIVE    SURGERY 

result  of  a  congenital  weakness  of  the  diaphragm,  usually  around  the  esoph- 
ageal opening.  This  weak  point  may  give  way  from  pressure  that  under 
normal  conditions  is  readily  withstood.  Bevan  records  a  case  that  was  ap- 
parently due  to  a  distended  colon  from  chronic  ol)struction  due  to  cancer 
of  the  left  side  of  the  colon.  It  is  important  to  recognize  whether  the 
hernia  is  purely  traumatic  or  is  due  to  a  congenital  weakness,  because 
the  location  of  the  incision  and  the  type  of  operation  are  usually  quite 
different  in  these  two  types.  Diaphragmatic  hernia  due  to  direct  injury  is 
usually  along  the  periphery  of  the  diaphragm  and  the  hernia  may  occur  im- 
mediately or  may  follow  months  or  years  after  the  injury.  Here  the  best  ap- 
proach is  probably  through  the  thorax.  In  the  congenital  type  the  hernia 
occurs  around  the  esophageal  opening  in  the  diaphragm,  and  in  such  a  loca- 
tion the  site  of  the  hernia  is  most  accessible  through  an  abdominal  incision,  as 
it  would  be  difficult  to  reach  the  defect  through  the  thorax. 

The  hernia  can  often  be  located  by  the  x-ray.  A  portion  of  the  stomach 
is  frequently  found  in  these  hernias  whether  they  be  traumatic  or  congenital. 
Other  viscera  are  also  often  contained  in  a  diaphragmatic  hernia.  The  case 
of  Bevan,  which  has  already  been  referred  to,  contained  a  portion  of  the  di- 
lated transverse  colon  through  an  opening  around  the  esophageal  outlet  of 
the  diaphragm.  Roentgenographic  examination  should  be  made  not  only  of 
the  stomach  but  of  the  complete  gastrointestinal  tract. 

Stuart  McGuire,  of  Richmond,  has  had  some  interesting  cases  in  which 
the  approach  was  through  the  thorax.  Here  the  incision  may  be  intercostal 
over  the  apparent  site  of  the  hernia.  Such  an  incision  should  be  long  and 
held  open  by  rib  spreaders.  Resection  of  the  eighth  or  ninth  rib  might  give 
better  exposure.  In  any  event  the  incision  should  be  sufficiently  long  to 
afford  ample  access  to  the  site  of  the  hernia.  The  lung  is  packed  off  with 
an  abundance  of  moist  gauze,  which  is  not  too  hot,  as  excessive  heat  will 
probably  do  more  harm  than  having  the  gauze  too  cold.  After  the  hernia 
is  reduced  the  diaphragmatic  opening  is  closed  by  interrupted  sutures  of 
tanned  catgut.  This  closure  is  made  in  the  line  of  least  resistance  and  if 
this  does  not  correspond  to  a  straight  line  the  closure  may  follow  the  outline 
of  a  T  or  an  L.  After  inserting  the  interrupted  sutures,  if  there  is  not  too  much 
tension,  a  separate  row  of  tanned  catgut  sutures  may  be  placed  over  the  first 
row. 

In  the  congenital  type  of  diaphragmatic  hernia  the  abdominal  approach 
is  much  superior  to  thoracic  incision.  An  excellent  exposure  is  made  by 
the  S-shaped  incision  of  Bevan,  which  begins  just  below  the  ensiform  carti- 
lage and  goes  outward  parallel  to  the  costal  cartilage  to  the  middle  or  outer 
portion  of  the  rectus  muscle,  then  downward  to  about  the  level  of  the  umbili- 
cus and  then  slants  outward  again.  The  hernial  contents  are  reduced  by 
traction.  Sometimes  this  is  best  done  by  opening  the  lesser  neritoneal  cavity 
and  pulling  down  the  contents  from  behind  the  stomach.  Traction  must  be 
made  very  carefully,  as  hemorrhage  due  to  rough  manipulation  in  this  neigh-- 


HERNIA  507 

borliood  is  embarrassing.  The  suction  of  the  pleural  cavity  during  respira- 
tion tends  to  draw  the  abdominal  contents  back  through  the  hernial  opening 
and  this  adds  to  the  difficulty  of  the  operation.  The  hernial  opening  is 
closed  with  stout  tanned  or  chromic  catgut  in  much  the  same  manner  as  the 
conjoined  tendon  is  sutured  to  Poupart's  ligament  in  an  inguinal  hernia. 
The  opening  is  sutured  snugly  around  the  esophagus.  Balfour  found  that  a 
large  opening  in  the  diaphragm  was  best  closed  by  suturing  it  in  a  T-shaped 
manner,  suturing  the  anterior  portion  in  a  straight  line  and  the  posterior  por- 
tion in  a  line  at  a  right  angle  to  the  anterior  row  of  sutures.  It  is  exceedingly 
important  to  place  the  sutures  so  they  will  have  a  minimum  of  tension. 
The  omentum  near  the  stomach  or  near  the  colon  may  be  fixed  to  the  ab- 
dominal wall  by  a  few  interrupted  sutures  of  catgut  so  there  will  be  less 
tendency  for  these  viscera  to  return  to  the  hernial  site.  If  intratracheal 
anesthesia  is  available  and  can  be  skillfully  given  it  will  add  considerably 
to  the  ease  with  which  this  operation  can  be  done,  though  it  is  not  a  necessity. 
The  patient  is  placed  in  bed  in  the  head  elevated  position  to  reduce  the  pres- 
sure upon  the  diaphragm  by  the  abdominal  viscera. 

Other  forms  of  internal  hernia  are  occasionally  met,  but  they  require  no 
special  type  of  operation.  The  diagnosis  of  such  cases  is  very  infrequently 
made  before  operation  and  the  operation  is  usually  performed  to  relieve 
symptoms  of  intestinal  obstruction.  Hernia  of  the  small  intestines  through 
the  rent  in  the  mesocolon  after  gastroenterostomy  was  formerly  a  rather 
common  occurrence.  This  is  avoided  by  suturing  the  edges  of  the  opening  of 
the  mesocolon  to  the  stomach  wall,  which  is  best  done  according  to  the  sug- 
gestion of  McArthur  by  placing  the  posterior  sutures  between  the  rent  in 
the  mesocolon  and  the  posterior  wall  of  the  stomach  before  the  stomach  and 
jejunum  are  clamped.  Hernia  into  any  of  the  intraabdominal  fossae  re- 
quires reduction  with  closure  of  the  fossa  if  possible  by  tanned  or  chromic 
catgut.  The  treatment  of  the  intestine  depends  upon  the  condition  of  the  in- 
testine and  may  demand  a  resection,  or  an  enterostomy,  or  both. 


CHAPTER  XXIII 
ABDOMINAL  INCISIONS 

The  first  and  last  stages  of  every  abdominal  operation  are,  respectively, 
the  making-  and  the  closing  of  the  incision;  and  they  constitute  an  im- 
portant part  of  the  success  or  failure  of  the  operation.  The  location  of 
the  incision  depends  largely  upon  the  region  of  the  abdomen  to  be  oper- 
ated upon.  Satisfactory  exposure  is  always  not  only  desirable,  but  usu- 
ally necessary,  though  there  may  be  different  views  of  what  constitutes  satisfac- 
tory exposure.  In  acute  appendicitis,  for  instance,  an  incision  over  the  region 
of  the  appendix  that  is  just  large  enough  to  admit  the  finger  for  palpation 
is  often  satisfactory,  but  in  chronic  appendicitis,  or  particularly  where  bands 
or  other  pathology  are  suspected,  a  short  incision  which  merely  permits 
removal  of  the  appendix  without  other  examination  of  the  abdominal  viscera, 
is  often  followed  by  a  continuance  of  the  patient's  symptoms.  Here  an  incis- 
ion near  the  midline  with  exploration  either  by  palpation  or  sight  of  all  the 
abdominal  viscera  should  be  made. 

In  operations  upon  the  upper  abdomen  many  surgeons  employ  a  trans- 
verse incision,  claiming  that  the  aponeurosis  of  the  muscles  of  the  abdomen 
is  least  injured  by  it,  and  that  the  nerves,  particularly  the  nerves  to  the  recti 
muscles,  are  saved.  If  a  transverse  incision  is  made  in  the  upper  abdomen 
it  will  be  necessary  to  divide  the  recti  muscles,  and  in  order  to  secure 
their  ends  they  are  sutured  to  the  aponeurosis  in  front  and  behind  before 
they  are  divided.  This  may  be  done  by  making  an  incision  through  the 
skin  and  superficial  fascia  down  to  the  aponeurosis,  opening  the  abdom- 
inal cavity  in  the  midline  just  enough  to  admit  the  finger  and  then  fasten- 
ing the  recti  muscles  to  their  sheaths  by  two  parallel  rows  of  sutures  through 
the  anterior  and  the  posterior  sheath.  The  abdominal  contents  are  protected 
during  this  suturing  by  inserting  the  finger  through  the  small  median  open- 
ing. These  sutures,  according  to  Willy  Meyer,  should  preferably  not  en- 
ter the  peritoneal  cavity,  and  this  may  be  accomplished  by  using  a  strong 
full  curved  needle.  After  these  rows  of  sutures  are  placed  the  recti  muscles 
with  the  fascia  are  divided  transversely  between  the  stitches  and  the  wound 
is  retracted.  Occasionally  such  an  incision  may  be  advisable,  but  as  a  rule  the 
longitudinal  incision  or  the  modified  longitudinal  incision  gives  the  best  exposure 
and  is  easily  closed. 

For  operations  on  the  gall  bladder,  the  bile  ducts,  or  the  pyloric  end  of 
the  stomach,  the  Bevan  incision  or  a  modification  of  it  gives  excellent  exposure.  . 
This  incision  begins  just  below  the  ensiform  cartilage,  runs  downward  and 

508 


ABDOMINAL   INCISIONS 


509 


outward  to  about  the  middle  of  the  rectus  muscle,  and  then  downward  to 
a  little  above  the  level  of  the  umbilicus,  when  it  is  again  carried  downward 
and  outward  for  two  or  three  inches.  The  fascia  is  divided  along  the  straight 
incision  and  the  rectus  muscle  in  the  direction  of  its  fibers.  If  it  is  neces- 
sary for  a  full  exposure  the  rectus  muscle  is  cut  across  obliquely  along  with 
the  fascia  at  the  upper  part  of  the  wound  and  also  at  its  lower  portion. 
It  is  not  often  necessary  to  make  the  ol^lique  incision  through  the  rec- 
tus muscle  at  the  lower  portion  of  the  Avound  but  it  can  be  done  with  but 
little  complication  in  closing  the  wound  or  in  weakening  the  abdominal  scar. 


Fig.  480. — Lines  for  abdominal  iiKi.-ii.ns.  i'lie  incisions  near  the  midline  in  the  epigastric  region 
fire  the  iJevan  incisions,  right  and  left.  The  vertical  incision  to  the  outer  side  of  the  right  Bevan  incision 
is  the  intraabdominal  incision  for  nephrectomy.  The  incision  near  the  right  anterior  superior  _  iliac  spine 
is  the  McBurney  incision  for  appendicitis.  The  lowest  curved  incision  is  the  Pfannenstiel  incision.  ^  Just 
above  this  is  the  transversed  incision  of  Judd  for  double  hernia.  An  incision  to  the  right  of  the  midline 
between    the    navel    and    the   pubis    is    for    general   pelvic   and    lower   abdominal   work. 


Through  such  an  incision  most  operations  in  the  right  upper  abdomen  can  be 
performed  and  access  to  the  gall  bladder  and  gall  ducts,  pylorus  and  pyloric 
end  of  the  stomach  is  excellent  (Fig.  480).  This  incision  is  also  quite  satis- 
factory when  applied  to  the  left  side. 

A  median  incision  above  the  umbilicus  is  sometimes  employed  though  it 
should,  as  a  rule,  be  avoided.  A  median  incision  either  above  or  below  the  um- 
bilicus, while  avoiding  injury  to  any  nerves  that  may  supply  the  recti  mus- 
cles, cuts  through  a  thin  portion  of  the  abdominal  wall  where  the  fascia  af- 


510  OPERATIVE    SURGERY 

fords  unsatisfactory  marg'ins  for  a  sound  scar.  Of  course,  in  epigastric  hernia 
a  median  incision  closed  by  slight  overlapping  of  the  aponeurosis  is  essen- 
tial. If  an  incision  is  carried  through  the  rectus  muscle,  closure  is  more  satis- 
factory because  two  distinct  layers  of  fascia  and  the  rectus  muscle  between 
them  add  a  bulk  of  large  stable  tissue  to  the  edges  of  the  wound,  instead  of 
merely  a  thin  single  plane  of  fascia  as  occurs  in  the  median  line.  If  an  in- 
cision is  made  along  the  inner  third  of  the  rectus  muscle,  or  if  the  fibers  are 
split  along  the  junction  of  the  middle  and  inner  thirds  but  little  of  the  rectus 
muscle  is  affected  by  the  destruction  of  the  nerve  supply,  and  the  proper 
suturing  of  the  aponeurosis  of  the  large  fiat  muscles  of  the  abdomen,  which 
constitutes  the  anterior  and  posterior  sheath  of  the  rectus  muscle,  should 
secure  satisfactory  union. 

If  the  surgeon  is  not  fully  satisfied  of  the  necessity  of  a  long  incision  in 
the  upper  abdominal  region,  as  in  explorations  about  the  gall  bladder,  the 
central  part  of  the  Bevan  incision  may  be  made  and,  if  the  occasion  demands, 
the  incision  can  be  extended  both  upward  and  downward.  Not  infrequently 
when  it  is  desired  to  explore  the  gall  bladder  and  remove  the  appendix,  the 
appendix  may  be  removed  through  a  McBurney  incision  and  the  condition 
of  the  gall  bladder  ascertained  through  a  short  two  inch  incision  through 
the  rectus  muscle.  This  incision  over  the  gall  bladder  is  made  first  because 
if  the  gall  bladder  is  found  diseased  the  incision  is  extended  and  the  ap- 
pendix removed  through  this  one  incision,  but  if  there  is  no  trouble  with 
the  gall  bladder  or  the  structures  in  its  neighborhood  this  wound  is  closed 
and  the  appendix  removed  through  a  McBurney  incision. 

Operations  on  the  cardiac  end  of  the  stomach,  for  diaphragmatic  hernia, 
or  on  the  spleen,  are  satisfactorily  done  through  a  left  Bevan  incision.  This 
begins  as  on  the  right  side  just  below  the  ensiform  cartilage,  goes  downward 
and  outward  parallel  with  the  edge  of  the  left  costal  cartilage  to  about  the 
middle  of  the  rectus  muscle,  then  vertically  down  to  just  above  the  level  of 
the  umbilicus,  splitting  the  fibers  of  the  rectus  muscle,  and  then  downward 
and  outward  obliquely  for  a  sufficient  distance  to  give  satisfactory  exposure. 
By  carrying  the  vertical  portion  of  this  incision  nearer  to  the  outer  border  of 
the  rectus  muscle  a  somewhat  better  exposure  of  the  spleen  is  obtained  than 
if  the  vertical  part  were  nearer  the  middle  of  the  muscle.  This,  of  course, 
must  be  left  to  the  exigencies  of  the  case,  but  it  should  also  be  remembered 
that  the  nerves  of  the  recti  and  other  abdominal  muscles  run  in  the  upper 
abdomen  approximately  a  transverse  course  and  more  of  the  rectus  muscle 
will  be  saved  if  the  vertical  incision  is  made  nearer  toward  its  inner  border. 

Removal  of  the  kidney  when  indicated  because  of  considerable  enlarge- 
ment, such  as  a  tumor,  is  often  best  done  through  a  vertical  incision  along  the 
outer  border  of  the  rectus  muscle.  This  should  extend  from  just  below  the 
margin  of  the  costal  cartilage  to  well  below  the  level  of  the  umbilicus.  The 
peritoneal  cavity  may  be  opened  though  often  the  peritoneum  can  be  stripped 
away  from  the  abdominal  wall  and  the  pedicle  of  the  kidney  reached  without 
opening  the  peritoneum.  Whether  this  is  done  depends,  of  course,  upon  the 
size,  shape,  and  character  of  the  kidney  growth. 


ABDOMINAL   INCISIONS  511 

An  incision  fov  iiml)ili(';il  liernia  should  l)c  transverse,  and  usually  el- 
liptical including  the  umbilicus  along  with  the  surrounding  skin  in  the 
mass  of  tissue  to  be  excised.  If  there  is  occasion  to  make  a  long  incision  near 
the  umbilicus,  as  for  the  removal  of  an  intraabdominal  tumor  in  its  neigh- 
borhood, the  incision  is  supposed  to  be  placed  to  the  left  of  the  umbil- 
icus, because  the  round  ligament  to  the  liver  goes  somewhat  to  the  right  of 
the  midline  from  the  umbilicus  to  the  liver.  Such  an  incision,  however,  is  but 
rarely  indicated.  It  is  best  to  excise  the  umbilicus  while  making  this  incision 
in  order  that  the  wound  may  be  more  satisfactorily  closed.  Occasionally,  in 
operations  upon  the  cardiac  end  of  the  stomach  or  for  a  tumor  of  the  liver  that 
is  difficult  of  access  an  atypical  incision  must  be  made.  Sometimes  it  may  be 
advisable  to  make  a  flap,  such  as  is  used  in  exposure  of  the  heart,  with  the 
base  outward  over  the  ribs,  with  two  transverse  parallel  incisions  and  a  third 
incision  connecting  the  two  ends  of  the  parallel  incisions  at  the  midline.  The 
ribs  and  costal  cartilage  are  divided  or  fractured  and  the  flap  is  turned  back 
for  full  exposure. 

In  operations  upon  the  lateral  margins  of  the  abdominal  wall  the  kidney 
is  the  most  frequent  object  of  attack.  Here  the  incision  of  W.  J.  Mayo  gives 
exceedingly  satisfactory  exposure  and  inflicts  a  minimum  of  injury  on  the 
abdominal  muscles.  This  incision  can  be  used  in  operations  on  the  kidney, 
the  pelvis  of  the  kidney,  or  the  upper  ureter.  It  begins  at  a  point  about  two  and 
a  half  inches  external  to  the  spinous  process  of  the  lower  dorsal  vertebrae  near 
the  outer  margin  of  the  erector  spinae  muscle  over  the  upper  border  of  the 
twelfth  rib,  or  even  higher.  (Fig.  590.)  The  incision  is  carried  downward  and 
somewhat  forward  along  the  outer  margin  of  the  quadratus  lumborum  to  about 
an  inch  above  the  crest  of  the  ileum,  where  it  is  carried  forward  parallel  to  the 
crest  of  the  ileum  as  far  as  may  be  necessary  for  satisfactory  exposure.  The  tri- 
angle just  beneath  the  twelfth  rib  at  the  upper  portion  of  the  wound  is  exposed 
by  incising  the  external  and  the  internal  oblique,  the  transversalis  and  the  latis- 
simus  dorsi  muscles  and  the  transversalis  fascia  is  freely  opened.  The  twelfth  rib 
is  well  freed  along  its  lower  border  almost  to  its  articulation  and  the  rib  is 
retracted  strongly  upward  while  the  erector  spinae  muscle  is  retracted  back- 
ward. Sometimes  the  twelfth  rib  may  be  dislocated  or  fractured  to  give  even 
larger  exposure.  The  muscles  are  divided  along  the  lower  part  of  the  wound 
as  far  as  may  be  necessary  in  the  general  direction  of  the  skin  incision.  Care 
should  be  taken  to  avoid  injury  to  the  iliohypogastric  and  the  ilioinguinal 
nerves. 

When  fixation  of  the  kidney  is  contemplated  a  shorter  incision,  such  as 
was  employed  by  Edebohls,  is  satisfactory.  Here  the  twelfth  rib  and  the 
erector  spinae  muscle  are  recognized  and  a  vertical  incision  is  made  from  the 
twelfth  rib  downward  close  to  the  outer  edge  of  the  erector  spinae  muscle. 
This  goes  almost  to  the  crest  of  the  ileum.  The  fibers  of  the  latissimus  dorsi  are 
exposed  and  are  split,  but  not  cut  across.  The  erector  spinae  is  retracted 
inward  but  its  sheath  is  not  opened.  The  sheath  of  the  quadratus  lumborum  is 
opened  along  its  outer  margin  for  the  whole  of  the  wound.    By  keeping  about 


512  OPERATIVE    SURGERY 

one  ineli  below  the  rib  injury  to  the  pleura  may  be  avoided.  The  transversalis 
fascia  is  divided  and  the  perirenal  fat  is  exposed.  The  iliohypogastric  and  the 
ilioinguinal  nerves  must  l)e  protected  at  the  lower  portion  of  the  wound. 

Incisions  in  the  abdomen  for  operations  below  the  umbilicus  are  often 
made.  In  acute  appendicitis  where  there  is  no  reasonable  doubt  of  the  diag- 
nosis, the  McBurney  incision  is  most  satisfactory.  This  is  made  in  the  direction 
of  the  fibers  of  the  external  oblique  and  is  about  two  inches  long  with  the  cen- 
ter of  the  incision  on  a  line  between  the  anterior  superior  spine  and  the  umbil- 
icus, and  about  one  and  a  half  or  two  inches  from  the  anterior  superior 
spine.  In  women  when  an  exploration  of  the  pelvic  organs  is  desired,  the  in- 
cision is  carried  much  lower  and  further  inward.  After  cutting  down  to  the 
aponeurosis  of  the  external  oblique,  this  aponeurosis  is  split  in  the  direction 
of  its  fibers  throughout  the  length  of  the  skin  incision.  The  iliohypogastric 
nerve  is  identified,  and  the  fibers  of  the  internal  oblique  and  transversalis 
muscles,  which  run  practically  parallel  in  this  region,  are  separated  at  a 
sufficient  distance  above  the  nerve  to  avoid  its  inclusion  in  the  sutures  when 
the  incision  is  closed.  Failure  to  do  this  is  often  followed  by  an  unneces- 
sarily painful  scar.  The  fibers  of  these  muscles  are  best  divided  by  inserting 
the  points  of  closed  blunt-pointed  scissors  and  then  spreading  them  in  the  di- 
rection of  the  fibers  of  the  muscle.  Two  fingers  are  placed  between  the  sepa- 
rated fibers  to  enlarge  the  incision.  Then  retractors  hold  the  split  fibers 
apart  while  the  peritoneum  is  incised.  (Figs.  561-564.)  If  this  incision  is  made 
further  inward  and  downward,  not  infrequently  the  deep  epigastric  vessels  ap- 
pear along  its  inner  margin  and  they  must  be  retracted  or  doubly  clamped  and 
divided.  Here  the  fibers  of  the  internal  oblique  and  transversalis  terminate 
in  an  aponeurosis  which  may  be  split  in  the  direction  of  its  fibers,  and  the 
margin  of  the  rectus  muscle  is  strongly  retracted  inward  without  being  divided. 

In  general  exploration  of  the  lower  abdominal  cavity  an  incision  just 
to  the  right  of  the  midline  is  very  satisfactory.  This  may  be  carried  from 
about  the  level  of  the  umbilicus  to  the  pubis.  The  sheath  of  the  rectus 
muscle  is  cut  along  the  junction  of  the  middle  and  inner  thirds  of  the  muscle. 
If  the  incision  is  made  nearer  the  midline  too  little  support  is  furnished 
the  sutured  wound  by  the  rectus  muscle,  while  further  out  too  much  of  the 
rectus  muscle  is  injured  by  destroying  its  nerve  supply.  After  incising  the 
fascia  the  fibers  of  the  rectus  muscle  are  split  and  held  apart  by  retractors 
while  the  peritoneal  cavity  is  opened.  Sometimes  the  epigastric  artery 
runs  in  this  region  and  not  infrequently  a  large  branch  is  given  off  which 
may  cross  the  line  of  incision  at  its  upper  portion.  Some  operators  ad- 
vise retracting  the  muscle  outward  instead  of  dividing  its  fibers  in  order 
to  save  all  of  the  nerve  supply.  As  below  the  semilunar  fold  all  of  the 
aponeurosis  that  constitutes  the  sheath  of  the  rectus  is  in  front  of  the  rectus 
and  none  behind,  this  dislocation  of  the  inner  edge  of  the  rectus  muscle  may 
make  a  weak  spot  that  would  not  occur  if  the  muscle  were  left  attached 
along  its  inner  border  and  its  fibers  split. 


ABDOMINAL    INCISIONS  513 

Operations  upon  the  sigmoid  and  the  left  colon  may  be  done  through  an  in- 
cision somewhat  to  the  left  of  the  midline  made  in  the  same  manner  as  has 
just  been  described  for  incision  to  the  right  of  the  midline.  If  it  is  planned 
to  resect  the  bowel  for  cancer  an  ample  incision  along  the  outer  border  of  the 
rectus  muscle  will  be  necessary.  The  incision  of  Sir  Astley  Cooper  for  ex- 
posure of  the  iliac  vessels  is  now  rarely  if  ever  emploj^ed,  because  the  iliac  vessels 
can  be  much  better  exposed  by  an  incision  somewhat  to  one  side  of  the  midline 
with  the  patient  in  the  Trendelenburg  position.  The  old  incision  was  ad- 
vised because  of  the  ancient  surgical  fear  of  entering  the  peritoneal  cavity. 


Fig.   481. — The   incision   of  Judd   for    double   inguinal   hernia. 

The  bladder  may  be  exposed  by  a  median  incision  running  up  from  the  pubis 
for  a  sufficient  distance.  Here  the  recti  and  the  pyramidalis  muscles  over- 
lap and  there  is  an  abundance  of  muscle  fibers  to  protect  the  Avound  if  con- 
ditions permit  of  primary  suturing  of  the  muscle. 

A  transverse  or  Pfannenstiel  incision  is  used  by  some  operators  for  ex- 
posure of  structures  in  the  pelvis.  This  is  carried  across  the  abdomen  with 
a  slight  convexity  downward,  the  lowest  point  of  the  convexity  lying  about 
two  inches  above  the  pubis.  The  incision  maj^  be  so  placed  that  most  of  it 
comes  within  the  region  of  the  pubic  hair.  The  skin  and  subcutaneous  tis- 
sue are  dissected  up  along  the  upper  margin  as  a  flap.  The  aponeurosis  of 
the  external  oblique   is  divided  in  the  general  direction  of  the   skin  incis- 


514  OPERATIVE    SURGERY 

ion.  The  upper  poi-lioii  of  1lie  flap  of  tlie  ai)oiieiirosis  is  dissected  and  a 
vertical  incision  is  made  ))et"\veen  the  recti  muscles.  This  gives  satisfae- 
tory  exposure  and  in  certain  instances  may  be  indicated.  If  there  is  any 
suspicion  of  infection,  however,  it  should  not  l)e  employed  for  too  much  raw 
surface  is  exposed.  It  is  also  difficult  to  enlarge  this  incision  satisfactorily 
if  the  surgeon  finds  that  more  space  is  necessary  than  he  had  first  anticipated. 
An  excellent  incision  in  double  hernias  is  that  which  is  used  by  E.  S. 
Judd  (Fig.  481).  It  is  a  transverse  incision  from  just  external  to  one  in- 
ternal inguinal  ring  to  a  corresponding  point  on  the  opposite  side.  Both 
hernias  can  thus  be  readily  exposed.  It  is,  of  course,  only  carried  through 
the  skin  and  superficial  fascia,  the  rest  of  the  hernia  behig  operated  upon 
according  to  the  technic  that  mav  seem  indicated. 


CLOSURE  OF  ABDOMINAL  INCISIONS 

The  method  of  closing  abdominal  incisions  depends  partly  upon  the 
character  of  the  incision  and  largely  upon  whether  it  is  located  above  or 
below  the  umbilicus.  The  physiologic  action  of  the  muscles  of  the  abdomen 
and  the  movement  of  the  abdominal  contents  is  so  different  in  these  two 
regions  that  the  procedures  for  closing  incisions  made  above  or  below  the 
navel  must  differ  materially.  Below  the  umbilicus  there  is  but  little  motion 
of  the  abdominal  muscles.  The  aponeurosis  below  the  semilunar  fold  of 
Douglas  is  in  front  of  the  recti  muscles  instead  of  being  half  in  front  and 
half  behind  as  it  is  above  this  point.  The  recti  muscles  themselves  act  as 
a  buffer  and  take  considerable  strain  from  the  thick  aponeurosis  in  front 
but  where  the  aponeurosis  splits  above  the  semilunar  fold  of  Douglas,  half 
going  in  front  and  half  behind  the  recti,  if  the  posterior  layer  is  not  accurately 
closed  its  retraction  forms  a  point  of  least  resistance  and  the  abdominal  con- 
tents can  easily  force  apart  the  fibers  of  the  rectus.  A  potential  hernia  re- 
sults. 

Incisions  beloAV  the  umbilicus  are  frequently  made  just  to  the  side  of 
the  midline  so  that  the  portion  of  rectus  muscle  between  the  incision  and  the 
midline  is  very  small,  and  even  if  it  looses  its  nerve  supply  but  little  harm 
is  done.  Above  the  umbilicus,  howcA^er,  incisions  are  rarely  made  in  the 
midline  and  are  usually  along  the  middle  or  outer  portion  of  the  rectus  so  that 
a  considerable  portion  of  this  muscle  may  be  deprived  of  its  nerve  supply 
and  can  hardly  be  depended  upon  to  resist  the  intraabdominal  pressure. 

The  main  reason,  however,  for  the  difference  in  the  types  of  suturing 
above  and  below  the  umbilicus  is  the  motion  of  the  muscles.  Below  the  um- 
bilicus there  is  comparatively  little  muscle  movement  during  normal  res- 
piration, whereas  above  the  umbilicus  it  is  always  pronounced.  The  action 
of  the  diaphragm,  which  forces  the  liver  and  stomach  up  and  down  during 
respiration,  and  the  expansion  and  contraction  of  the  thorax  cause  consider- 
able motion  of  the  upper  abdominal  wall  during  each  respiratory  act.  When 
there  is  vomiting  or  any  unusual  tension  within  the  abdomen,  particularly  with 


AP.nOMlN'AI;    INCISIONS  515 

tlie  i)atii'iit  \y\\\u:  in  Ix'd,  llir  luiixiimini  force  ;i  pfx'n  rs  lo  he  excrled  around 
the  epig-asslriiiiii,  as  the  very  act  of  vomiting  means  that  the  stomach  itself 
is  eomprossecl  by  llie  ad  ion  of  the  diaphragm  and  the  abdominal  muscles 
M'hicli  lie  o^■el•  the  stomach. 

It  is  not  generally  safe  to  trust  to  layers  of  catgut  sutures  in  any  wound  above 
tlie  umbilicus.  The  insertion  of  a  number  of  interrupted  sutures  of  catgut  may  be 
safe,  but  the  constant  motion  of  the  muscles  in  this  neighborhood  makes  a  soft- 
ened or  weakened  catgut  suture  likely  to  give  way  and  the  abdominal  contents 
may  protrude  beneath  the  skin  or  through  the  skin  wound  itself.  To  obviate  this 
some  operators  insert  tension  sutures  of  silkworm-gut  in  addition  to  the  catgut 
sutures.  These  are  placed  after  closing  the  peritoneum  but  before  suturing  the 
muscles  or  fascia.  The  muscles  and  fascia  are  then  closed  with  separate  layers  of 
catgut  sutures  and  the  skin  is  sutured  in  the  usual  manner,  the  tension  sutures 
being  tied  last  of  all  and  the  skin  protected  either  by  placing  ganze  over  the 
skin  wound  and  tying  the  sutures  over  them,  or  by  threading  the  sutures 
through  a  segment  of  fine  rubber  tubing.  This  method  is  usually  satisfactory 
but  it  seems  unnecessary  to  insert  the  catgut  sutures  because  it  places  an  ad- 
ditional burden  of  absorption  on  the  tissues,  cuts  ofl  a  certain  amount  of  nu- 
trition from  the  edges  of  the  repairing  wound,  and  to  some  extent  permits 
small  cavities  to  form  between  the  layers  of  sutures.  If  an  operator  feels 
that  it  is  necessary  for  purposes  of  safety  to  insert  four  or  five  tension  sutures 
of  silkworm-gut,  as  he  knows  this  material  will  hold,  it  seems  a  simpler  mat- 
ter to  add  a  few  extra  silkworm-gut  sutures,  making  the  number  eight  or 
ten,  and  depend  solely  upon  them.  This  method  was  found  very  satisfactory 
in  the  early  days  of  surgery  and  has  been  used  with  much  success  by  the 
late  Joseph  Price  and  his  successors.  The  scar  left  is  not  as  smooth  as  the 
scar  after  careful  layer  suturing,  but  Avhen  tension  sutures  are  added  to 
layer  sutures  there  is  but  little  difference  in  the  scar.  If  the  wound  is  closed 
by  through  and  through  sutures  of  silkworm-gut  which  are  inserted  at  in- 
tervals of  about  three-fourths  of  an  inch  it  is  best  not  to  close  the  skin  with 
a  continuous  suture.  If  this  is  done  any  broken  down  fat  or  serum  that 
may  accumulate  in  the  grasp  of  the  interrupted  suture  cannot  find  a  ready 
escape  and  may  predispose  to  infection. 

In  closing  incisions  above  the  umbilicus  which  are  either  transverse  or  nearly 
transverse,  the  recti  muscles  should  be  fixed  to  their  sheaths  before  being  divided. 
This  method  as  used  by  Willy  Meyer  and  others  has  been  described.  Here  the 
wound  may  be  closed  with  interrupted  catgut  sutures  but  silkworm-gut  is  excel- 
lent. The  tension  on  a  transverse  wound  during  straining  or  vomiting  is 
marked  because  of  the  action  of  the  recti  muscles. 

In  closing  other  types  of  incisions  above  the  umbilicus  which  are  either 
longitudinal  or  oblique,  the  edges  of  the  peritoneum  are  grasped  with  liem- 
ostats  so  that  the  peritoneum  is  drawn  w^ell  into  the  wound.  Stout  silk- 
worm-gut in  a  large  needle  is  inserted,  beginning  at  the  loAver  end  of  the 
wound,  taking  a  small  bite  of  skin,  a  considerable  amount  of  the  fascia 
over  the  rectus  muscle,   a   small  part   of   the   muscle,   and  a   generous   bite 


516  OPERATIVI':    SURGERY 

of  the  posterior  aponeurosis  and  peritoneum.  The  needle  is  returned  from 
within  out  in  a  similar  manner  and  each  end  of  the  suture  is  grasped  with 
a  large  hemostat.  If  one  wishes  to  be  particularly  careful  each  end  of  the 
silkAvorm-gut  ma.y  be  threaded  on  a  needle  and  inserted  from  within  outward. 
This,  hoAvever,  seems  to  be  an  unnecessary  refinement  for  unless  there  are 
twice  as  many  needles  as  there  are  sutures  if  the  needle  is  passed  from  within 
outward  it  must  eventually  penetrate  the  skin,  and  each  time  it  penetrates 
the  skin  it  may  become  contaminated,  when  it  should  be  either  boiled  or 
discarded.  As  a  matter  of  practice  when  the  skin  has  been  well  disinfected 
there  seems  but  little  danger  in  inserting  the  needle  from  without  inward  on 
one  side  and  from  within  outward  on  the  other,  as  has  just  been  described. 
These  sutures  are  all  placed  before  they  are  tied  and  the  ends  of  each  suture 
are  grasped  with  hemostats.  After  they  are  all  placed  an  assistant  and  a 
nurse  forcibly  raise  the  ends  of  the  sutures  on  each  side  of  the  wound  so  that 
the  edges  of  the  wound  are  slightly  lifted  up.  The  operator  then  presses 
together  the  abdominal  wall  on  each  side  of  the  wound,  thus  forcing  the 
peritoneum  together  because  it  must  slide  down  on  each  side  of  the  suture 
to  what  corresponds  to  the  apex  of  a  triangle  (Fig.  482).  While  the  sutures 
are  held  in  this  position  they  are  tied  one  at  a  time,  just  snugly  enough  to 
obtain  reasonably  firm  closure.  The  assistant  and  nurse  hold  the  other  sutures, 
merely  releasing  one  as  it  is  about  to  be  tied.  In  this  way  the  sutures  are 
tied  under  equal  tension  and  evenly.  If  this  precaution  is  not  taken  the  pa- 
tient sometimes  strains  before  all  the  sutures  are  tied  and  breaks  them  or 
tears  the  tissues  and  to  secure  coaptation  it  may  be  necessary  to  tie  the 
sutures  quite  tightly  which,  of  course,  produces  necrosis  and  predisposes 
to  infection.  If  there  is  equal  tension  on  each  suture,  however,  and  they 
are  tied  in  the  manner  described,  the  strain  on  the  wound  is  distributed 
over  the  combined  sutures  in  the  same  manner  as  the  strain  on  the  strands 
of  a  cable,  which  can  withstand  great  tension  as  long  as  the  strands  are 
together,  but  if  they  are  separated  it  will  easily  snap.  Furthermore,  the 
peritoneum  is  brought  well  in  apposition  and  as  all  the  structures  of  the  ab- 
dominal wall  are  held  in  uniform  tension  in  the  grasp  of  the  same  suture 
there  is  less  tendency  for  any  one  structure  to  be  cut  by  the  suture.  These 
sutures  are  left  in  about  ten  days  or  two  weeks.  It  is  best  not  to  take 
them  all  out  the  same  day,  but  to  remove  half  of  the  sutures  at  one  time  and 
the  other  half  a  few  days  later. 

In  wounds  near  the  midline  below  the  umbilicus  layer  sutures  are  satisfac- 
tory except  where  pus  is  encountered  in  the  abdominal  cavity  or  where  b,y  reason 
of  contamination  there  seems  a  probability  of  infection  of  the  wound.  Here 
through  and  through  sutures  should  be  placed  in  the  same  manner  as  above 
the  umbilicus.  In  suturing  a  wound  in  layers  below  the  umbilicus  the  peri- 
toneum is  brought  together  by  fine  continuous  mattress  sutures  of  tanned 
or  chromic  catgut.  The  suture  is  begun  at  the  loAver  angle  of  the  wound 
and  the  short  end  is  tied  and  clamped  with  a  hemostat  to  hold  it  steady. 
The    suture    is    carried    back    and    forth    as    a    continuous    mattress    stitch, 


abdo:mixal  incisions 


517 


catehino-  a  p'oocl  orasp  on  tlie  transversalis  fascia  and  the  edges  of  the 
peritoneum.  A  mattress  -suture  used  in  this  Avay  turns  out  the  raw  edges, 
exposes  no  raw  surface  to  the  abdominal  cavity,  and  secures  a  firm  hold  on 


Fig.   482. — ^Method   of   closing   incisions   above   the   umbilicus. 

the  delicate  peritoneum.  The  suture  is  tied  at  the  upper  angle  of  the  wound. 
The  wound  in  the  rectus  muscle  is  closed  with  a  continuous  lock  stitch  of 
plain  catgut  and  is  brought  together  with  very  little  tension.  Muscle  is  highly 
organized  tissue  and  withstands  pressure  badly.     The  merest  approximation 


518  OPKKATIVE    SURGERY 

of  tlie  divided  fibers  of  tlie  rectus  is  much  better  than  a  tight  suture  because 
the  tight  suture  Avill  cut  the  muscle  or  impair  its  nutrition.  The  aponeurosis 
or  the  external  sheath  of  the  rectus  muscle  is  closed  with  a  continuous  lock 
stitch  of  tanned  or  chromic  catgut,  about  number  one  in  size.  If  this  row  is 
accurately  ap^Dlied  there  is  no  need  for  further  reinforcing  it  except  possibly 
where  it  is  anticipated  that  there  will  be  considerable  distention.  Here  a 
few  interrupted  sutures  of  tanned  or  chromic  catgut  are  placed  through  the 
fascia  over  the  continuous  lock  suture  and  going  well  back  into  the  fascia.  It 
must  be  borne  in  mind,  however,  that  extra  tension  sutures  are  not  entirely 
without  danger  because  the  relief  of  tension  on  the  midline  sutures  also  means 
cutting  off  nutrition  to  the  edges  of  the  fascial  wound  which  may  delay  healing, 
though  in  some  instances  tension  sutures  may  be  justifiable.  The  skin  is 
closed  with  a  continuous  subcuticular  suture  of  00  tanned  or  chromic  catgut. 
If  the  skin  is  very  thin  and  flabby  a  continuous  mattress  suture  of  fine 
tanned  catgut  is  used.  No  tension  suture  other  than  those  just  mentioned 
should  be  used  when  an  abdominal  wound  is  closed  in  layers.  If  tension  sutures 
of  silkworm-gut  are  demanded,  it  would  be  much  better  to  use  a  few  more 
and  close  the  whole  wound  with  silkworm-gut,  as  has  been  described  for  in- 
cisions above  the  umbilicus. 

In  the  McBurney  or  muscle-splitting  operation  the  wound  is  closed  in 
layers  with  catgut.  The  peritoneum  here  may  be  united  with  a  mattress  or 
a  purse-string  suture  of  plain  catgut.  The  transversalis  and  internal  oblique 
muscles,  whose  fibers  have  been  split,  are  closed  with  a  few  sutures  of  plain 
catgut.  A  continuous  lock  stitch  of  plain  catgut  is  used  in  the  aponeurosis 
of  the  external  oblique  and  the  skin  is  closed  with  a  continuous  subcuticular 
suture  of  fine  tanned  or  chromic  catgut.  Muscles  are  particularly  irritated 
by  chemicals  in  catgut,  so  when  muscle  is  united  to  muscle,  plain  catgut  which 
is  readily  absorbed  should  be  used ;  though  when  muscle  is  united  to  fascia, 
as  in  a  hernia  operation,  tanned  or  chromic  catgut  is  advisable. 

In  drainage  cases  of  appendicitis  where  the  McBurney  incision  has  been 
made,  one  or  two  interrupted  silkAvorm-gut  sutures  are  used,  catching  all 
layers  of  the  abdominal  wall  and  tying  the  sutures  close  to  the  tube  or  cigarette 
drain  which  comes  out  at  the  outer  angle  of  the  wound.  To-prevent  pocketing 
the  rest  of  the  wound  is  lightly  packed  with  iodoform  gauze. 

In  operations  on  the  kidney  the  lower  portion  of  the  incision  may  be  difficult 
to  approximate  accurately  by  through  and  through  interrupted  sutures,  and  these 
wounds  can  be  closed  in  tAvo  layers,  using  tanned  or  chromic  catgut  either  in  a 
continuous  lock  suture  or  as  interrupted  sutures.  The  through  and  through 
method,  however,  is  excellent  here.  At  the  upper  posterior  angle  a  drain  is 
brought  out.  The  transverse  ijicision  of  Pfannenstiel  is  closed  by  suturing  the 
peritoneum  in  the  usual  way,  the  fibers  of  the  rectus  muscle  with  a  loose  continu- 
ous lock  stitch  of  plain  catgut,  and  the  aponeurosis  of  the  external  oblicpie  and 
the  sheath  of  the  rectus  with  a  continuous  lock  stitch  of  tanned  or  chromic  catgut. 
The  skin  may  be  closed  by  a  continuous  mattress  suture  of  fine  tanned  or  cliromic 
catgut,  or  with  horsehair,  fine  silkworm-gut  or  silk.     These  latter  materials  pro- 


ABDOMINAL    INCISIONS  519 

diice  somewhat  less  reaction  than  catgut  and  eventually  make  a  somewhat 
less  conspicuous  scar  than  is  obtained  even  by  an  accurate  subcuticular  suture 
of  fine  catgut.  Where  tlie  inconspicuousness  of  the  scar  is  a  very  desirable 
point,  as  in  operations  al)out  the  face  and  neck,  catgut  should  not  be  used,  as 
has  already  been  explained,  but  in  wounds  of  the  abdomen  a  subcuticular 
suture  of  fine  eatgut  makes  a  very  satisfactory  scar  with  no  stitch  marks, 
and  the  patient  is  often  gratified  that  there  are  no  stitches  to  be  removed. 

In  suprapubic  operations  upon  the  bladder  M'here  the  peritoneum  is  not 
entered  tliere  is  nearly  always  drainage  and  here  interrupted  sutures  of  silk- 
worm-gut are  verj-  satisfactory. 


CHAPTER  XXIV 

OPERATIONS  ON  THE  LIVER,  GALL  BLADDER,  BILE  TRACTS, 
PANCREAS  AND  SPLEEN 

Operations  upon  the  liver  itself  are  not  common.  Occasionally  an  abscess 
or  a  tumor  requires  operation  and  this  must  be  done  according  to  a  certain 
definite  technic.  Sometimes,  too,  ptosis  of  the  liver  requires  correction, 
though,  as  a  rule,  when  this  occurs  the  presence  of  other  prolapsed  organs, 
together  with  the  peculiar  structure  of  the  abdominal  wall  in  these  cases, 
makes  an  operation  for  prolapse  of  the  liver  unsatisfactory.  When  the 
prolapse  is  in  the  neighborhood  of  the  gall  bladder,  suturing  the  gall  blad- 
der to  the  abdominal  wall  helps  to  correct  the  ptosis.  A  U-shaped  incision 
is  made  in  the  abdominal  wall  with  its  concavity  upward  and  around  the 
lower  circumference  of  the  prolapsed  portion  of  the  liver.  The  transversalis 
fascia  is  cut  down  upon  but  is  not  incised  except  at  the  lowest  portion  of 
the  wound  where  a  transverse  cut  is  made  through  the  transversalis  fascia 
and  peritoneum.  The  other  tissues  in  the  U-shaped  incision  are  raised  from 
the  transversalis  fascia  and  peritoneum.  At  the  upper  level  of  the  reflected 
flap  another  transverse  incision  is  made  parallel  to  the  one  below  it  and  a  por- 
tion of  the  loose  lobe  of  the  liver  is  tucked  into  the  pocket  thus  formed  and 
fastened  Avith  sutures. 

When  there  is  complete  prolapse,  the  liver  may  be  replaced  and  fastened 
by  passing  coarse  sutures  of  catgut  or  silk  along  the  anterior  edge  of  the 
liver  and  tying  them  to  the  cartilages  of  the  ribs.  About  six  or  eight  of  these 
sutures  may  be  passed.  It  is  also  necessary  to  take  up  the  slack  in  the  abdom- 
inal wall  below  the  liver  in  order  to  afford  support.  This  may  be  done  by 
removing  an  oval-shaped  area  of  skin  and  fascia  from  the  midline  of  the  ab- 
dominal wall  and  suturing  the  edges  together  after  slightly  overlapping  them. 
In  the  method  of  Depage,  a  horizontal  incision  is  made  from  the  tip  of  the 
eleventh  rib  on  one  side  to  that  of  the  eleventh  rib  on  the  other,  and  then 
incisions  are  carried  downward  and  inward  from  the  extremities  of  this 
horizontal  incision  to  about  the  level  of  the  umbilicus,  terminating  external 
to  the  umbilicus.  These  incisions  are  one-half  the  length  of  the  original 
transverse  incision.  From  the  ends  of  these  incisions  on  a  level  with  and 
external  to  the  umbilicus,  an  ellipse  is  made  Avhich  terminates  just  above 
the  pubis.  All  the  tissues  included  in  these  incisions  are  removed  and  the 
wound  is  sutured  to  make  a  T-shaped  scar. 

Operations  for  hepatic  abscess  are  common  in  tropical  or  semitropical 
countries.  The  kind  of  operation  depends  upon  the  location  of  the  abscess 
and  may  be   through   the   thoracic   route   or   through   the   abdominal   route. 

520 


LIVER,    GALL   BLADDER,    BTLE    TRACTS,    ETC.  521 

Occasioually  the  abscess  may  be  so  situated  as  to  render  either  one  of  these 
routes  permissible,  Avhen  a  choice  Avill  depend  to  a  large  extent  upon  the 
adhesions  around  the  abscess.  The  final  diagnosis  is  the  aspiration  of  the  ab- 
scess. If  this  is  followed  immediately  by  operation  through  the  track  of 
aspiration  but  little  harm  is  done,  but  if  pus  is  found  and  the  operation  is 
postponed  for  a  day  or  two,  the  pus  may  leak  along  the  needle  track 
and  infect  either  the  peritoneum  or  the  pleural  cavity,  according  to  the  re- 
gion through  which  the  needle  was  introduced.  If  a  fine  needle  is  used 
such  a  danger  is  reduced  to  a  minimum,  but  the  pus  is  often  thick  and  can- 
not run  through  a  fine  needle  so  it  may  be  necessary  to  use  a  coarser  one. 
If  the  abdominal  route  is  chosen  for  opening  an  abscess  which  is  adher- 
ent to  the  parietal  peritoneum  the  situation  is  much  simpler  if  the  in- 
cision can  be  made  through  the  area  of  adhesions.  Not  infrequently,  however, 
this  is  impossible  and  if  the  liver  has  been  exposed  and  found  to  be  free  from 
adhesions  the  region  of  the  abscess  must  be  surrounded  with  gauze  and  as- 
piration repeated.  If  pus  is  obtained  an  opening  is  made  by  thrusting  in  sharp- 
pointed  forceps  and  stretching  them,  or  by  inserting  the  actual  cautery.  If  it  is 
possible  to  do  so.  it  would  be  better  to  pack  around  the  abscess  and  then  open  it 
after  forty-eight  hours.  Sutures  in  an  inflamed  liver  will  rarely  hold  and  iodoform 
gauze  packing  must  be  used,  but  a  few  sutures  of  coarse  catgut  inserted  at  a  short 
distance  from  the  region  of  the  abscess  serve  to  hold  the  liver  against  the  abdomi- 
nal wall  before  the  packing  is  placed.  The  sutures,  of  course,  cannot  replace  the 
packing  and  alone  will  not  prevent  the  contamination  of  the  abdominal  cav- 
ity. They  merely  serve  to  lessen  the  amount  of  packing  necessary.  The  ab- 
scess cavity  is  explored  with  the  finger  to  determine  the  possibility  of  a 
pocket  or  a  secondary  abscess  before  a  tube  is  inserted.  After  introducing 
a  large  tube,  gauze  is  packed  around  it  and  to  prevent  its  displacement  the 
tube  is  fastened  to  the  edge  of  the  wound  with  a  suture  of  silkworm-gut. 
The  tube  may  be  connected  with  a  retainer  into  which  the  pus  is  drained  or 
it  may  be  necessary  for  the  pus  to  drain  on  the  dressings  which  are  frequently 
renewed.    It  is  probably  best  not  to  irrigate  these  cavities. 

When  the  abscess  points  toward  the  diaphragm  it  is  opened  through 
the  thorax.  After  locating  the  abscess  by  an  aspirating  needle,  about  two 
inches  of  the  ninth  or  tenth  rib  are  excised  over  the  region  of  the  abscess  and 
the  pleural  cavity  is  protected  by  suturing  or  by  packing  with  gauze  held  in 
position  by  a  few  catgut  stitches.  The  aspirating  needle  is  again  used,  and 
following  it  as. a  guide  the  abscess  in  the  liver  is  opened  by  thrusting  in 
closed  sharp-pointed  forceps   or  by  the  actual  cautery. 

The  chief  difficulty  in  excision  of  a  tumor  of  the  liver  is  the  control  of 
hemorrhage.  If  the  tumor  is  small  and  situated  along  the  margin  of  the 
liver  but  little  trouble  is  experienced.  The  incision  may  be  made  with  an 
electric  cautery  and  a  V-shaped  portion  of  the  liver  removed,  wdiich  includes 
the  tumor,  the  wound  being  closed  with  coarse  catgut  sutures.  These  sutures 
are  inserted  with  a  large  blunt-pointed  liver  needle,  or  a  large  curved  needle  is 

V 


522  OPERATIVE    SURGERY 

thrust  tliroiigli  the  liver  e^'e  first,  is  threaded  and  then  witlidrawn.  A  probe 
can  also  be  used  in  emergency,  the  suture  being  hitched  around  the  blunt  end  of 
the  probe  or  passed  through  the  eye  at  the  other  end  if  the  probe  has  an  eye 
at  its  opposite  extremity.  In  a  large  tumor  an  effort  may  be  made  to  con- 
trol the  bleeding  temporarily  by  an  elastic  tube  thrown  around  the  pedicle 
of  the  growth  or  carried  through  the  liver  itself  by  a  cannula.  A  cannula 
through  which  a  small  soft  rubber  catheter  can  be  carried  is,  with  its  trocar, 
thrust  through  the  liver  tissue  back  of  the  tumor,  the  trocar  withdrawn,  and 
a  rubber  catheter  threaded  through  the  cannula.  The  catheter  is  tied  or 
clamped  on  one  side  of  the  growth  and  another  catheter  is  similarly  placed  on  the 
other  side  of  the  growth  and  tied.  They  act  as  an  elastic  tourniquet.  McDill 
compresses  the  vessels  by  an  enterostomy  clamp  protected  with  rubber  tub- 
ing, and  others  have  recommended  interlocking  sutures  of  stout  catgut  placed 
around  the  tumor  before  it  is  excised.  All  sutures  in  the  liver  should  be 
of  stout  material  and  tied  no  tighter  than  necessary  to  secure  hemostasis, 
otherwise  they  will  cut  through.  Occasionally  the  incisions  can  be  made  in 
such  a  Avay  as  to  excise  a  tongue  of  liver  tissue  along  the  margins  of  the  tu- 
mor, leaving  two  flaps  to  be  approximated  to  each  other  by  sutures.  The 
incision  is  often  made  Avith  an  electric  cautery  to  avoid  hemorrhage.  It  must 
be  remembered  that  the  blood  pressure  in  the  liver  is  very  low  and  firm 
pressure  upon  it  by  packing  or  by  apposition  of  raw  surfaces  will  control 
hemorrhage.  Either  a  pedunculated  graft  or  a  free  graft  of  omentum  can 
be  sutured  to  the  bleeding  surface  of  the  liver  and  will  often  control  the 
bleeding.  If  hemostasis  is  secured  by  the  application  of  stomach  or  intes- 
tinal clamps  and  sutures  Avill  not  hold  satisfactorily,  the  clamps  may  be 
left  in  position  for  forty-eight  hours  and  then  removed. 

Exposure  of  the  contents  of  the  upper  abdomen,  including  the  gall  blad- 
der and  gall  ducts,  is  satisfactorily  accomplished  by  the  Bevan  incision,  or 
its  modifications.  The  vertical  portion  of  the  incision  is  carried  down  the 
inner  portion  of  the  rectus  in  order  to  preserve  the  nerve  supply  for  a  maxi- 
mum amount  of  this  muscle. 

Removal  of  the  gall  bladder,  or  cholecystectomy,  is  an  operation  fre- 
quently performed.  A  satisfactory  method  of  doing  this"  is  from  below  up- 
ward, and  it  is  necessary  to  have  an  incision  beginning  just  below  the  ensi- 
form  cartilage  in  order  to  obtain  satisfactory  exposure.  The  method  as 
described  by  E.  S.  Judd  is  the  technic  that  has  been  employed  for  many  years 
and  with  much  satisfaction  at  the  Mayo  clinic.  The  fundus  of  the  gall 
bladder  is  clamped,  preferably  with  a  sponge-holding  forceps,  in  order  not 
to  tear  the  tissues,  and  is  pulled  upward  and  forward  until  the  pelvis 
of  the  gall  bladder  is  exposed.  The  liver  is  brought  up  into  the  wound 
as  far  as  possible  and  the  surrounding  tissues  are  protected  by  gauze  pack- 
ing. A  second  sponge-holding  forceps  is  applied  to  the  pelvis  of  the  gall 
bladder  just  above  the  cystic  duct.  The  tissues  around  the  cystic  duct 
are  torn  with  forceps  or  incised  with  scissors  and  by  blunt  dissection,  in- 
serting closed  scissors  or  forceps  and  spreading  them  open,  the  neck  of  the 


LIVER,    GALL    BLADDER,    BILE    TRACTS,    ETC. 


523 


Fig.   483. — Exposure   of   the   cystic   duct   in    cholecystectomy. 


Fig.   4S4. — Double   ligation  and  clamping  of   the   cystic   duct. 


524 


OPERATIVE    SURGERY 


gall  bladder  and  tlie  cystic  duct  are  tlioroughly  exposed.  It  is  important 
to  demonstrate  that  the  cystic  duct  runs  into  the  gall  bladder  and  to  isolate 
it  thoroughly  by  blunt  dissection  before  it  is  clamped  (Fig.  483).  The  cystic 
duct  and  the  cystic  artery  may  be  clamped  together  or  separately  if  they 
are  not  in  immediate  proximity  as  often  happens.  After  the  cystic  duct  is 
doubly  clamped  with  a  sufficient  amount  of  the  duct  between  the  forceps 
to  prevent  retraction,  the  duct  is  divided.  It  is  well  to  disinfect  the  stump 
of  the  cystic  duct  with  a  drop  of  carbolic  on  a  probe,  though  this  is  not 
necessary-.  If  exposure  is  difficult  for  double  clamping,  the  cystic  duct  may 
be  tied  with  tanned  or  chromic  catgut  close  to  the  common  duct  and  a  clamp 


Fig.    485. — The   cystic   artery   has   been    clamped   and   the   gall    bladder   is   dissected   out   from    below    upward. 


placed  on  the  neck  of  the  gall  bladder.  Two  ligatures  are  applied  on 
the  cystic  duct  stump  at  a  short  distance  from  each  other.  One  is  cut 
short  and  the  other  is  left  long  and  brought  out  in  the  wound  (Fig.  484). 
The  severed  cystic  duct  and  the  pelvis  of  the  gall  bladder  are  elevated  by 
gentle  traction  and  a  forceps  is  applied  behind  and  close  to  the  gall  blad- 
der to  grasp  any  vessels  in  this  region.  It  is  important  on  the  one  hand 
not  to  wound  the  gall  bladder  and  so  soil  the  field,  and  on  the  other 
to  avoid  injury  to  the  hepatic  duct.  By  making  traction  on  the  pelvis 
of  the  gall  bladder  and  the  severed  cystic  duct,  the  tissues  can  be  brought 
into  such  prominence  that  they  can  be  grasped  Avith  but  little  danger  of  in- 
juring the  gall  bladder  or  the  hepatic  duct  (Fig.  485).  If  an  unusual  ves- 
sel is  divided  or  the  cystic  artery  retracts,  a  small  sponge  of  dry  gauze  in 


LTVKR,    GAT.r,    l!l,AI)l)i;iJ.    lilLI'.    TRACTS,    ETC. 


525 


forceps  is  pressed  upon  llic  l)loedino'  spot.  If  it  cannot  be  isolated  satis- 
factorily a  larger  amount  of  dry  gauze  is  held  in  position  a  few  minutes  and 
gradually  I'emoved  along  the  edges  of  the  raw  surface  until  the  bleeding  vessel 
is  located.  The  vessel  is  then  grasped,  preferably  with  small  forceps,  and  is 
tied.  Pressure  with  gauze  will  control  the  bleeding  temporarily  until  the 
oozing  has  been  checked,  and  then  only  the  larger  vessels  M'ill  bleed.  In- 
discriminate catching  of  points  in  a  bloody  field  in  this  region  will  al- 
most certainly  result  in  disaster  and  will  cause  the  loss  of  more  blood. 
A  firm  pack  of  dry  gauze  held  in  position  for  a  few  minutes  and  then  care- 


Fig.  486. — The  cystic  artery  has  been  tied  and  the  bed  of  the  gall  bladder  is  sutured. 

fully  removed  from  the  margins  of  the  wound  until  the  main  injured  vessel 
is  demonstrated  will  greatly  aid  in  securing  hemostasis  in  this  region.  Any 
bleeding  more  than  a  simple  oozing  should  be  thoroughly  controlled  before 
removing  the  rest  of  the  gall  bladder,  for  the  gall  bladder  serves  as  a  point  of 
traction  and  renders  the  exposure  of  the  field  easier,  while  even  a  small  amount 
of  blood  running  down  from  the  bed  of  the  gall  bladder  makes  it  more  diffi- 
cult to  locate  bleeding  points  around  the  cystic  duct.  If  the  gall  bladder 
is  thick  it  can  usually  be  dissected  from  the  liver  so  as  to  leave  a  small 
amount  of  fascia  in  its  bed  which  facilitates  suturing  the  resulting  raw 
surface.  After  removing  the  gall  bladder  and  securing  the  cystic  duct  and 
artery  the  other  bleeding  points  are  controlled  by  transfixing  the  tissues 
immediately   around  them  with   a   fine   curved   needle   threaded   with   plain 


526 


OPERATIVE    SURGERY 


catgut  and  tying  the  suture  moderately  firmly.  The  stump  of  the  cystic 
duct,  the  common  duct,  and  hepatic  duct,  should  be  well  demonstrated  to 
avoid  possible  injury  to  them. 

The  raw  surface  left  by  removal  of  the  gall  bladder  is  closed  by  suturing  the 
tissues  together  with  a  continuous  lock  stitch  of  plain  catgut,  beginning  at  the 
lower  portion  of  the  wound  and  ending  at  the  margin  of  the  liver  (Fig.  486) .  The 
suturing  is  just  tight  enough  to  control  bleeding.  The  ends  of  this  suture  are  tied 
at  the  margin  of  the  liver  and  left  long-.  A  medium  sized  rubber  tube  is  carried 
down  to  the  stump  of  the  cystic  duct  by  cutting  one  hole  near  the  end  of  the  tube 
and  passing  the  long  ends  of  one  of  the  ligatures  over  the  stump  of  the 
cystic  duct  through  the  end  of  the  tube  and  through  this  oi^ening.     The  tube 


Fig.  487. — A  rubber  tube  is  carried  to  the  stump  of  the  cystic  dtjct  over  the  long  end  of  the 
ligature  and  is  fastened  to  the  edge  of  the  liver  by  the  ends  of  the  suture  that  closes  the  bed  of  the  gall 
bladder.     The  suture   line  is  behind   the  tube. 


is  further  fixed  in  position  by  bringing  it  over  the  bed  of  the  gall  bladder 
and  tying  around  it  the  long  ends  of  the  suture  that  had  been  used  to  whip 
over  the  bed  of  the  gall  bladder  (Fig.  487).  At  the  beginning  of  this  suture 
the  end  should  be  left  quite  long  and  after  the  tube  has  been  fixed  in  posi- 
tion, as  has  been  described,  fat  from  the  edge  of  the  omentum  or  from  the 
round  ligament-  of  the  liver,  or  from  both,  is  brought  down  to  the  bottom 
of  the  tube  and  fixed  in  this  position  by  a  needle,  into  which  has  been  threaded 
this  long  end  which  passes  several  times  through  the  fat  of  the  omentum 
or  round  ligament.  Sometimes  the  fat  of  the  round  ligament  is  abundant 
and  easily  available.  Occasionally  the  omentum  is  short  and  contains  but 
little  fat.     Often  both  of  these  structures   can  be   utilized.     Care   must   be 


LIVER,    GAT.L    BLADDER,    BILE    TRACTS,    ETC. 


527 


taken  to  see  that  ^vhen  the  omentum  is  brought  up  the  colon  is  not  unduly 
constricted  or  kinked.  This  covering  of  the  region  of  the  tube  with  fat  is  im- 
portant because  it  protects  the  duodenum  and  prevents  it  from  being  drawn 
up  to  the  raw  surface  under  the  liver.  In  one  case  of  mine  after  cholecys- 
tectomy in  which  this  precaution  was  not  taken,  adhesions  were  dense  be- 
tween the  duodenum  and  the  liver  and  caused  marked  symptoms.  In  the 
second  operation  these  adhesions  were  divided  and  a  free  graft  of  omentum 
was  applied  over  the  duodenum.  There  has  been  no  recurrence  of  the  symp- 
toms, the  operation  having  been  done  about  five  years  ago.  The  wound  is 
closed  with  silkworm-gut  sutures,  as  has  been  described. 

Murat  Willis,  of  Richmond,  buries  the  stump  of  the  cystic  duct  and  closes 
the  wound  without  the  insertion  of  a  tube.  This  technic  is  satisfactory  in 
the  majority  of  cases,  but  occasionally  the  cystic  duct  will  open  even  when 
securely  tied  wdth  a  double  ligature  and  a  small  amount  of  bile  will  escape. 
This  may  not  be  due  to  an  improper  application  of  the  ligature,  but  to 
the  fact  that  nature  makes  unusual  efforts  to  overcome  obstruction  of  the 
bde  ducts  and  pancreatic  duets  and  leakage  may  occur  from  necrosis  where 
the  suture  was  applied.  Then,  too,  particularly  in  thin  gall  bladders  it  may 
be  difficult  or  impossible  to  leave  a  sufficient  amount  of  fascia  in  the  bed  of 
the  gall  bladder  to  hold  the  sutures.  Here  the  sutures  must  be  taken  in 
the  liver  substance  and  occasionally  injury  of  a  small  duct  will  cause  leakage 
of  bile.  Leakage  of  bde  that  accumulates  around  a  fresh  wound  is  irritat- 
ing and  causes  numerous  adhesions  and  is  best  drained  away.  The  tube 
also  directs  externally  the  current  of  serum  or  lymph  that  is  poured  out  from 
the  w^ound,  w^hereas  otherwise  the  exudate  w^ould  accumulate  about  the 
cystic  duct  and  probably  infiltrate  around  the  foramen  of  Winslow  and 
the  tissues  in  its  neighborhood.  AVhile  this  serum  might  not  be  septic  it 
causes  considerable  irritation.  The  tube  is  properly  protected  by  fat.  The 
fatty  adhesions  that  result  appear  to  give  less  trouble  than  the  firm  adhesions 
that  follow  the  irritation  of  bde.  Hertzler  has  pointed  out  that  adhesions' 
are  denser  along  the  periphery  of  a  virulent  inflammation  than  in  its  cen- 
ter, and  that  a  marked  irritation  resulting  from  mechanical  or  chemical 
means  or  from  a  mdd  bacterial  infection  is  followed  by  firmer  adhesions 
than  occur  about  the  center  of  a  virulent  infection.  This  can  be  demonstrated 
clinically  by  finding  adhesions  to  structures  around  an  appendix  that  has  been 
previously  acutely  inflamed  while  the  appendix  itself  is  free,  or  by  seeing  the  scar 
of  a  duodenal  perforation  itself  free  from  adhesions  after  healing  has  taken  place 
with  dense  adhesions  at  points  some  distance  from  it. 

The  method  of  Murat  Willis  is  excellent  when  no  marked  infection  is  present, 
or  when  a  connective  tissue  bed  is  left  after  removing  the  gall  bladder,  and  is 
particularly  indicated  when  a  cholecystectomy  is  done  in  conjunction  with  a 
pyloroplasty. 

Cholecystotomy  is  now  employed  rather  infrequently  because  in  chole- 
cystitis the  infection  is  in  the  wall  of  the  gall  bladder,  just  as  it  is  within 
the  substance  of  the  tonsil  in  tonsillitis,   and  drainage  of  the  lumen  of  the 


528  OPERATIVE    SURGERY 

gall  bladder  often  fails  to  cure.  When,  however,  stones  are  contained  in 
a  gall  bladder  that  appears  fully  to  have  recovered,  or  when  there  is  marked 
infection  and  the  condition  of  the  patient  makes  it  wise  to  do  as  little  as  possi- 
ble, choleeystotomy  is  indicated.  The  gall  bladder  is  exposed  and  after  ex- 
ploring the  other  structures  to  determine  any  pathology  outside  of  the  gall 
bladder  the  fundus  is  clamped,  preferably  wdth  mosquito  forceps  or  Allis 
forceps,  and  drawn  into  the  Avound.  A  trocar  and  cannula  are  thrust  into 
the  gall  bladder  and  the  bile  is  withdrawn.  This  may  also  be  done  by  a 
large  aspirating  needle  or  the  cannula  may  be  connected  with  a  suction 
apparatus.  The  opening  made  by  the  trocar  and  cannula  is  enlarged  by 
thrusting  in  forceps  or  scissors  and  spreading  the  blades  apart,  or  by  an 
incision.  The  mucosa  of  the  gall  bladder  is  examined  and  the  edges  of 
the  incision  are  grasped  with  three  hemostats  at  about  equal  distance  from 
each  other.  The  rest  of  the  bile  is  removed  by  gently  inserting  a  strip 
of  dry  gauze.  Any  gall  stones  that  are  obvious  are  removed  by  a  scoop 
or  by  forceps.  After  as  many  stones  as  possible  have  been  removed  in 
this  manner  the  finger  is  inserted  in  the  gall  bladder  and  often  imbedded 
stones  may  be  found  that  cannot  be  otherwise  detected.  A  tube  about 
a  third  of  an  inch  in  diameter,  of  moderately  firm  rubber,  and  with  one 
opening  cut  near  its  end  is  inserted.  This  is  fixed  in  position  by  passing 
a  fine  tanned  or  chromic  catgut  suture  through  the  margins  of  the  gall 
bladder  and  the  wall  of  the  tube.  This  suture  is  tied  and  the  ends  are 
left  long.  A  purse-string  suture  of  fine  tanned  or  chromic  catgut  in  a  fine  nee- 
dle is  inserted.  This  is  passed  about  half  an  inch  from  the  margin  of  the  gall 
bladder  wound  and  as  it  is  slowly  tied  down  the  raw  edges  are  tucked  in 
by  an  assistant,  while  the  gall  bladder  is  steadied  by  being  grasped  with 
forceps  just  beyond  the  purse-string  suture.  After  the  edges  have  been  com- 
pletely tucked  in  the  suture  is  tied  snugly  three  times  and  fastened  with  a 
needle  to  the  parietal  peritoneum  to  hold  the  gall  bladder  up.  This  pre- 
vents it  from  sagging  and  secures  better  drainage.  The  tube  is  brought 
out  at  the  upper  portion  of  the  Avound.  There  is  no  occasion  for  gauze  pack- 
ing around  the  tube,  as  such  a  junction  is  Avater  tight  under  any  reasonable 
pressure  that  may  occur  and  the  turned  in  margins  of  the  gall  bladder  Avound 
act  as  a  valve.  The  tube  is  left  in  ten  days  or  tAvo  Aveeks.  In  severe  infection  it 
should  remain  in  longer.  If  it  is  difficult  to  remove  the  tube  Avhen  it  should 
be  removed  a  large  safety  pin  is  passed  through  it  near  the  skin  and  gauze 
is  tucked  under  the  safety  pin  so  as  to  make  gentle  traction  on  the  tube. 
This  is  repeated  for  tAvo  or  three  days,  and  the  suture  binding  the  tube  grad- 
ually cuts  through  the  tissue  Avhen  the  tube  is  removed  Avith  but  little  pain  and 
no  bleeding. 

Operations  upon  the  common  bile  duct  are  indicated  on  account  of  a  con- 
tained stone  or  obstruction  by  a  stricture.  When  stone  is  present  the  duct 
is  incised  over  the  site  of  the  stone  unless  the  stone  is  moA^able  or  is  in  an 
inaccessible  portion  of  the  duct.     When  the  stone  is  movable  the   common 


LIVER,    GALL    BLADDER,    BILE    TRACTS,    ETC.  529 

duct  is  opened  just  iiil cnial  to  the  cystic  duct  aud  the  stone  is  worked  into  this 
incision  whore  it  is  extracted.  The  exposure  should  be  ample  and  is  af- 
forded 1)y  tlie  type  of  incision  advised  in  operations  on  the  gall  bladder. 
The  surrounding  structures  are  well  protected  with  gauze,  particularly  the 
foramen  of  Winslow.  The  gauze  should  be  moist  and  is  gently  and  carefully 
placed.  Roughness  in  this  region  is  very  likely  to  cause  shock  or  a  reaction 
of  protest  by  the  tissues,  which  will  later  excite  spasm  of  the  upper  ab- 
dominal muscles  with  consequent  embarrassment  of  respiration  and  a  tend- 
ency to  congestion  of  the  lung  and  pneumonia.  Any  fatty  or  loose  tissue 
over  the  common  duct  is  dissected  away  and  the  relation  of  the  hepatic 
artery  and  portal  vein  to  the  common  duct  is  borne  in  mind.  The  duct  is 
opened  with  a  longitudinal  incision,  which  is  extended  if  necessary  either  to- 
ward the  liver  or  toward  the  duodenum.  Often  the  duct  in  obstruction  is 
greatly  enlarged  and  the  finger  is  readily  admitted.  If  the  finger  can  be  intro- 
duced the  hepatic  ducts  should  be  first  explored  and  then  the  common  duct. 
If  dilatation  is  not  sufficient  for  the  finger  the  exploration  may  be  made  with 
a  uterine  sound,  a  small  spoon-shaped  curet,  or  with  small  forceps.  After  re- 
moving the  stones  a  probe  is  introduced  into  the  duodenum.  It  is  sometimes  diffi- 
cult to  ascertain  whether  the  probe  is  in  the  duodenum  or  is  merely  pushing  for- 
ward the  ampulla  of  Vater.  If  a  small  spoon-shaped  curet  is  used  it  can  of- 
ten be  introduced  into  the  duodenum  and  may  withdraw  duodenal  contents. 

After  an  incision  in  the  common  duct  it  should  always  be  drained. 
This  may  be  done  by  a  T-shaped  tube  which  is  inserted  into  the  incision 
and  the  wound  in  the  common  duct  is  slightly  approximated  by  one  or 
two  sutures.  An  ordinary  drainage  tube,  however,  is  usually  satisfactory,  and 
is  cut  with  perforations  at  the  end  of  the  tube,  or  a  triangular  section  is  re- 
moved from  the  end  of  the  tube  so  as  not  to  obstruct  the  way  from  the 
hepatic  duct  to  the  distal  portion  of  the  common  duct.  A  catheter  with  many 
perforations  can  often  be  inserted  through  the  common  duct  into  the  duode- 
num or  up  toward  the  hepatic  duct  to  drain  the  bile  from  the  hepatic  duct 
through  the  tube.  Another  method  advocated  by  McArthur,  and  used  with 
much  success  by  Matas,  is  to  insert  a  small  rubber  catheter  through  the 
opening  of  the  common  duct  into  the  duodenum  and  to  instill  through  this 
tube  solutions  such  as  salt  solution  or  Locke's  solution,  which  can  be  readily 
absorbed  by  the  small  intestine.  This,  of  course,  is  only  necessary  in  grave 
sepsis.  A  cigarette  drainage  is  also  carried  down  to  the  opening  in  the  com- 
mon duct.  Halsted  advises  suturing  the  common  duct  and  draining  through 
the  stump  of  the  cystic  duct,  or,  if  impossible,  through  a  small  stab  wound 
in  the  common  duct.     This  is  an  excellent  method. 

Not  infrequently  such  cases  are  accompanied  by  dense  adhesions  to  the 
duodenum.  In  separating  these  adhesions  the  duodenum  itself  may  be  per- 
forated or  injured.  If  it  is  perforated  the  wound  should  be  sutured,  for  a 
duodenal  fistula  is  an  undesirable  thing  at  any  time,  but  when  it  complicates 
stone  in  the  common  duct  with  jaundice  it  is  exceedingly  serious.  If  the 
duodenum  has  been  injured  the  presence  of  the  drainage  tube  will  very  likely 


530  OPERATIVE    SURGERY 

divert  the  flow  of  lymph  toward  the  tube  and  away  from  the  injured  duodenum 
and  this  often  results  in  a  fistula.  The  presence  of  the  tube,  however,  is 
entirely  necessary  for  the  recovery  of  the  patient  and  when  the  duodenum  is 
injured,  after  the  perforation  has  been  closed  or  even  where  the  injury 
does  not  involve  a  perforation,  omentum  should  be  sutured  over  the  in- 
jured duodenum.  This  is  done  by  turning  up  a  piece  of  the  gastrocolic 
omentum  or  of  the  great  omentum.  Sometimes,  however,  the  adhesions 
in  such  a  case  are  so  dense  as  to  make  this  impracticable,  and  here  a  por- 
tion of  the  omentum  is  resected  and  applied  as  a  free  transplant  to  the  in- 
jured duodenum,  being  fastened  in  position  by  interrupted  sutures  of  chromic 
or  tanned  catgut.  This  graft  will  prevent  the  flow  of  lymph  from  the  duo- 
denum to  the  tube  and  actually  calls  for  a  larger  deposit  of  lymph  on  the 
duodenum  than  would  occur  if  the  graft  had  not  been  placed. 

Choleeystenterostomy  may  be  indicated  in  chronic  pancreatitis,  in  ob- 
struction of  the  distal  portion  of  the  common  duct,  or  in  cancer  of  the  head  of 
the  pancreas.  The  anastomosis  is  made  between  the  gall  bladder  and  the  duode- 
num or  the  stomach.  This  does  not  provide  as  satisfactory  drainage  in  inflamma- 
tion as  when  a  tube  is  inserted,  particularly  if  a  tube  is  placed  in  the  common  duct, 
because  there  is  no  occasion  for  any  marked  change  in  the  lymphatic  circulation, 
which  is  so  frequently  a  prominent  factor  in  the  benefleial  results  of  drainage. 
This  operation,  however,  should  relieve  the  pressure  in  the  common  duct  and  af- 
ford a  satisfactory  exit  for  the  bile  into  the  duodenum.  In  intense  jaundice 
following  malignant  disease  of  the  head  of  the  pancreas  it  is  a  good  x^allia- 
tive  measure  and  in  inflammation  of  the  head  of  the  pancreas,  which  is  often 
difficult  to  distinguish  from  malignant  disease,  the  operation  will  establish 
a  permanent  route  for  the  bile  which  will  relieve  some  of  the  factors  that 
promote  inflammation  in  the  head  of  the  pancreas. 

The  operation,  as  usually  performed,  consists  in  making  a  longitudinal 
incision  into  the  duodenum  and  anastomosing  this  incision  with  an  opening 
in  the  gall  bladder.  A  longitudinal  incision  splits  the  longitudinal  muscular 
fibers  of  the  duodenum,  which  are  external,  and  favors  the  closure  of  the 
opening,  as  each  time  the  longitudinal  fibers  contract  they  narrow  the  anas- 
tomotic opening  into  the  boAvel.  To  avoid  this  the  incision  in  the  duodenum 
should  be  transverse  instead  of  longitudinal.  After  exposing  the  duodenum 
and  gall  bladder  through  an  ample  incision  a  portion  of  the  fundus  of  the 
gall  bladder  that  can  be  placed  in  contact  Avith  the  duodenum  without  too 
much  tension  is  selected  and  the  place  for  the  incision  on  the  duodenum 
and  on  the  gall  bladder  is  marked  by  being  grasped  with  Allis  forceps.  If 
necessary  the  duodenum  is  slightly  mobilized  by  carefully  incising  the  peri- 
toneum along  its  outer  border.  A  fold  of  duodenum  caught  transversely  is 
fixed  with  forceps  used  for  lateral  blood  vessel  suturing.  The  forceps  have 
delicate  springs  and  blades  and  cannot  injure  the  bowel  wall.  There  is  no 
occasion  for  protecting  these  blades  with  rubber  tubes  (Fig.  488).  The  gall 
bladder  is  grasped  by  another  pair  of  forceps  after  stripping  back  the  bile. 


LIVER,    GALL   BLADDER,    BILE    TRACTS,    ETC. 


531 


Gauze  packing  is  placed  beneath  the  gall  Ijladder,  and  the  surrounding  tissues 
arc  protected  Avitli  gauze.  The  posterior  part  of  the  clamped  portion  of  duo- 
denum is  sutured  to  the  posterior  part  of  the  clamped  x>ortion  of  the  gall 
l)ladder  A\ith  a  small  curved  needle  carrying  fine  tanned  catgut  as  in  the  pre- 
liminary step  for  gastroenterostomy.  After  this  row  has  been  completed 
the  ends  of  the  suture  are  clamped  and  used  as  tractor  sutures.  This 
avoids  undue  manipulation  of  the  clamping  forceps  which  may  easily  be  dis- 
placed. The  clamped  portions  of  the  duodenum  and  gall  bladder  are  incised 
for  an  inch  or  more  and  gently  mopped  with  moist  gauze.  The  duode- 
num is  cut  transversely  as  it  is  clamped.  A  continuous  lock  stitch  unites 
the  cut  edges  along  the  posterior  margin  (Fig.  489).     This  suture  may  be  of 


Fig.  4SS. — The  aiuliur's   uK-tlioJ   of  chuleci-stuiitcrostoniy.     The   duodenum   is   clamped  at  a  right  angle  to   its 
axis   with   the   soft  bladed   forceps   used   for   lateral   blood   vessel   suturing. 

tanned  or  chromic  catgut,  or  if  the  patient  is  old  and  tissue  healing  is  likely 
to  be  poor,  especially  in  cancer  of  the  pancreas,  the  suture  material  had 
best  be  silk  or  linen.  This  inner  row  is  begun  at  either  the  upper  or  the 
loAver  angle  of  the  wound.  After  completing  the  suturing  of  the  posterior 
margins  of  the  wound  the  same  suture  is  continued  along  the  anterior  mar- 
gins. It  is  here  converted  into  a  right  angle  stitch  penetrating  the  whole 
wall,  or,  if  the  tissues  are  vascular,  it  is  placed  throughout  as  a  continu- 
ous lock  stitch  bringing  the  edges  of  the  wound  snugly  together  to  avoid 
the  possibility  of  hemorrhage.  When  the  point  of  beginning  is  reached  the 
suture  is  tied  to  the  long  end  left  at  the  first  knot  of  this  row  of  sutures. 
Three  or  more  knots  are  snugly  tied  and  the  ends  are  cut  short.  The  original 
line   of   sutures  is  then   continued   as   a   right   angle   continuous   stitch,   ap- 


532 


OPERATIVE   SURGERY 


proximating  as  broad  a  surface  as  can  be  brought  together  without  tension. 
When  this  row  is  completed  the  thread  is  tied  to  the  end  of  the  original 
knot  of  this  line  of  sutures.  As  the  greatest  point  of  tension  is  at  the 
ends  of  the  incision,  an  additional  mattress  suture  is  placed  at  these  points. 
The  wound  is  closed  without  drainage.  If  this  suturing  is  properly  done 
the  anastomosis  should  heal  satisfactorily,  even  in  cancer  cases  Avith  low 
nutrition,  but  if  drainage  is  jDlaced  it  may  cause  a  breaking  down  of  the 
suture  line. 

If  the  duodenum  is  inaccessible  the  anastomosis  may  be  made  with  the 
nearest  portion  of  the  stomach  with  almost  as   good  clinical  results.     The 


Fig.  489. — The  gall  bladder  is  similarly  clamped  and  a  row  of  sutures  unites  the  gall  bladde_r_  to 
the  duodenum.  The  gall  bladder  and  duodenum  are  then  incised  and  a  second  row  of  sutures,  uniting 
the  margins  of  the  wound,  is  placed. 

colon  should  never  be  used  because  of  the  probability  of  infection  of  the 
bile  tract  from  the  colon. 

Reconstruction  of  the  common  duct  may  be  indicated  as  a  result  of 
stricture  from  long  continued  inflammation  or  from  the  passage  of  stones,  or  be- 
cause of  injury  during  a  surgical  operation.  In  such  instances  the  bile  usually 
flows  through  an  external  fistula  and  often  there  is  also  inflammation  of  the 
bile  tracts  with 'chills  and  fever.  Numerous  efforts  have  been  made  to  re- 
construct the  common  bile  duct  by  grafting  or  bj"  transplantation  of  tissue. 
Grafts  of  fascia-  or  inverted  veins  or  similar  material  have  proved  unsatis- 
factory. While  they  may  appear  to  give  good  results  at  first,  any  tissue 
which  is  foreign  or  which  has  no  biologic  resistance  to  bile  will  react  pro- 
foundly.    There  will  be  dense  leucocvtic  infiltration  Avhicli  is  followed  later 


LIVER,    GALL   BLADDER,    BILE    TRACTS,    ETC,  533 

by  cicatricial  contraction  and  obliteration  of  tlie  reconstructed  duct.  The  recon- 
structed duct  closes  first  at  its  extremities  where  the  combination  of  the  sutured 
end  and  its  wall  fui'iiishes  a  maximum  contact  with  tlie  bile  and  where,  conse- 
quently, the  reaction  to  the  bile  would  be  greatest.  In  reconstruction  of  the  bile 
ducts,  of  the  intestines,  or  of  any  hollow  viscera,  whose  contents  may  irritate  other 
tissues,  only  tissues  should  be  used  which  have  a  biologic  resistance  to  the  nor- 
mal contents  of  the  duct  or  viscera  to  be  repaired.  A  sutured  intestine, 
for  instance,  will  heal  satisfactorily  if  the  raw  edges  are  inverted  and  the 
peritoneum  is  accurately  approximated,  though  the  fecal  current  is  con- 
stantly passing  over  the  cut  raw  edges  of  the  bowel  which  have  been 
turned  into  its  lumen.  If,  hoAvever,  we  were  to  keep  a  wound  in  the  skin 
bathed  with  fecal  matter,  as  the  inner  portion  of  the  intestinal  wound  is,  we 
would  expect  a  violent  reaction  and  if  healing  ever  occurred  it  would  be 
with  a  pronounced  scar.  This  is  because  the  walls  of  the  intestine  have  a 
certain  biologic  resistance  against  the  irritating  effects  of  the  contents  of  the 
bowel.  This  resistance  is  perfect  in  the  intact  mucosa  but  exists  to  some 
extent  in  the  deeper  layers  of  the  intestine.  The  study  of  a  segment  of  trans- 
planted vein  used  in  reconstruction  of  the  common  bile  duct  brought  these 
facts  vividly  to  mind.'^ 

The  method  of  A.  G.  Sullivan  in  which  a  rubber  tube  is  sutured  into 
the  hepatic  end  of  the  common  duct,  carried  into  the  duodenum,  and  sur- 
rounded by  neighboring  tissues  and  the  omentum  is  much  more  satisfac- 
tory than  the  reconstruction  of  the  common  duct  by  fascia,  because  the  tis- 
sues in  the  neighborhood  of  the  bile  tracts  and  the  omentum  have  more 
biologic  resistance  to  the  irritating  action  of  bile  than  fascia  transplanted  from 
a  distant  part! 

The  obvious  deduction  is  that  in  reconstructing  the  bile  ducts  tissues 
that  are  accustomed  to  the  presence  of  bile  should  be  used  and  should 
include  not  merely  the  epithelial  lining  but  the  submucosa.  The  constriction 
does  not  take  place  in  the  epithelial  lining,  but  in  the  submucosa  which  corre- 
sponds to  the  corium  or  derma  of  the  skin.  Even  though  a  tube  of  fascia 
by  which  the  common  duct  is  reconstructed  may  be  lined  with  epithelium, 
the  fascia  itself  reacts  to  the  irritating  effect  of  the  bile  and  sooner  or  later 
complete  occlusion  occurs.  To  prevent  eventual  occlusion,  then,  it  is  neces- 
sary^ not  only  to  have  an  epithelial-covered  surface  but  a  submucosa  with 
biologic  resistance  to  the  irritation  of  bile.  This  means  that  the  mucosa  and 
submucosa  of  the  bile  tracts  and  the  duodenum  must  be  used  wherever  possible. 

W.  J.  Mayo-  has  frequently  operated  by  bringing  the  duodenum  to  the 
hepatic  end  of  the  stump  of  the  common  or  hepatic  duct  and  suturing  it  in 
this  position.  The  duodenum  is  mobilized  and  the  stump  of  the  duct  to  be 
united  is  fastened  to  the  posterior  edge  of  a  short  incision  in  the  duodenum 
by  a  few  interrupted  sutures.     Other  sutures  are  placed  so  as  to  unite  more 


^Horsley,   J.    Slielton:     Reconstruction    of    the    Common    Bile    Duct,    Jour.    Am.    Med.    Assn.,    Oct.    12, 
1918. 

^Collected  Papers  of  the  Mayo  Clinic,  1915,  p.  274. 


534  OPERATIVE    SURGERY 

accurately  the  mucosa  of  the  duct  to  that  of  the  duodenum.  Then  a  rubber 
tube  is  placed  of  such  a  caliber  that  it  fits  not  too  snugly  into  the  duct,  reach- 
ing about  an  inch  into  the  hepatic  portion  of  the  duct  and  a  similar  distance 
into  the  duodenum.  It  is  fastened  in  position  with  a  catgut  suture  which  is 
absorbed  after  a  few  days  and  permits  the  tube  to  be  expelled.  The  rest 
of  the  wound  is  closed  by  layers  of  interrupted  tanned  or  chromic  catgut 
sutures  and  the  omentum  is  brought  over  the  whole  wound  and  fastened  in 
position  with  sutures. 

LeGrand  Guerry/^  of  Columbia,  S.  C,  has  utilized  this  principle  in  a  num- 
ber of  cases.  When  there  is  a  fistula  present  a  probe  is  inserted  through 
the  fistulous  tract  to  the  bile  duct.  It  is  best  to  dissect  outside  of  this  fistula 
as  far  as  possible  until  the  duodenum  has  been  exposed  and  the  upper  end 
of  the  bile  duct  recognized  by  the  end  of  the  probe.  The  tract  is  then  cut 
through  near  its  internal  termination  and  the  hepatic  stump  of  the  duct  is 
demonstrated.  He  mobilizes  the  duodenum  as  much  as  possible  and  incises  it 
down  to  the  mucosa.  The  mucosa  protrudes  and  gives  an  additional  amount 
of  tissue  which  is  more  readily  mobilized  than  the  whole  thickness  of  the 
duodenum.  A  tube  is  inserted  and  sutured  in  a  similar  manner  to  the  method 
of  W.  J.  Mayo.  If  the  closure  has  been  satisfactory  and  the  wound  well  sur- 
rounded by  omentum  drainage  is  unnecessary  as  it  may  predispose  to  the 
breaking  down  of  the  sutures. 

In  ascites,  due  to  cirrhosis  of  the  liver,  operations  have  been  devised 
for  side  tracking  the  blood  and  so  relieving  the  tension  in  the  portal  cir- 
culation. In  cirrhosis  of  the  liver  all  cases  of  ascites  are  probably  not 
due  solely  to  the  increased  tension  in  the  portal  circulation,  as  there  may 
be  other  factors.  A  diminution  of  the  portal  pressure,  however,  is  often 
followed  by  decrease  in  the  ascites.  Eck's  fistula  was  supposed  to  re- 
lieve this  condition  by  establishing  a  communication  between  the  portal 
vein  and  the  vena  cava.  This  has  not  proved  satisfactory  in  man  because  the 
large  amount  of  metabolic  products  that  are  contained  in  the  portal  circu- 
lation are  transferred  directly  to  the  general  circulation.  These  products 
should  first  go  through  the  liver,  where  they  are  changed-  by  the  liver  into 
nutritive  or  innocuous  material.  Unless  the  liver  intervenes,  they  become 
deleterious  when  introduced  directly  into  the  circulation.  A  small  part  of 
these  products,  hoAvever,  can  be  taken  care  of  by  the  general  circulation 
without  serious  effect.  The  operation  of  Talma  produces  an  anastomosis 
between  the  vessels  of  the  portal  circulation  and  those  of  the  general  circulation 
and  so  relieves  portal  pressure  without  admitting  to  the  general  circulation  more 
than  a  small  portion  of  the  material  absorbed  from  the  intestines.  This  operation, 
known  as  omentopexy,  which  was  devised  independently  by  Kutherford  Morison 
and  by  Talma,  is  sometimes  satisfactory  in  ascites  due  to  cirrhosis  of  the  liver. 
The  abdomen  is  opened  to  the  right  of  the  midline  above  the  umbilicus  and 
all  the  ascitic  fluid  is  evacuated.     With  dry  gauze  the  upper  surface  of  the 


^Guerry,  LeGrand:     Jour.   Anj.  Med.  Assn.,  Oct.   12.  191S. 


LIVER,    GALL   BLADDER,    BILE    TRACTS,    ETC.  535 

liver  is  rubbed  to  form  adhesions  between  the  liver  and  the  diaphragm.  The 
spleen  is  similarly  treated.  The  omentum  is  then  pulled  into  the  wound  and 
united  to  the  anterior  parietal  peritoneum  and  the  margins  of  the  wound. 
Usually  there  has  been  much  distention  with  the  ascites  and  after  the  fluid 
has  been  evacuated  the  abdominal  wall  can  be  everted  to  expose  a  con- 
siderable area  of  the  parietal  peritoneum.  The  omentum  is  sutured  around 
the  wound  as  far  from  the  incision  as  possible,  particularly  far  over  on 
the  left  side.  After  both  sides  are  sutured  the  wound  is  closed  with  in- 
terrupted sutures  of  silkworm-gut.  A  muscle  splitting  incision  is  made  after 
the  manner  of  McBurney  in  the  right  iliac  fossa  and  a  tube  is  inserted  to 
drain  off  the  fluid  in  the  pelvis.  This  is  necessary,  for  the  fluid  if  allowed 
to  accumulate  before  the  anastomosis  of  the  small  vessels  has  formed,  will 
interfere  with  the  union  of  the  omentum  to  the  peritoneum.  This  operation 
can  often  be  done  under  a  local  anesthetic. 

The  Mayos  have  modified  this  method  by  making  one  incision  on  the 
right  side  over  the  liver  as  near  the  deep  epigastric  and  internal  mammary 
vessels  as  possible  and  a  second  incision  four  inches  below  this  through  the 
rectus  muscle,  but  not  through  its  posterior  sheath.  After  separating  the 
muscle  from  its  posterior  sheath  extensively,  a  portion  of  the  omentum  is 
drawn  through  the  upper  part  of  the  incision  and  pulled  down  into  the  pocket 
where  it  is  fixed  in  position  with  a  few  sutures.  A  similar  procedure  can 
be  carried  out  on  the  left  side  and  the  intervening  segment  of  omentum  may 
be  united  to  the  parietal  peritoneum.  These  operations  done  in  the  early 
stage  afford  much  comfort  and  relief  from  ascites,  but,  of  course,  they  are 
not  curative  of  the  cirrhosis. 

In  tumors,  of  the  head  of  the  pancreas  or  the  duodenum  it  may  be  neces- 
sary to  transplant  the  end  of  the  common  duct  in  order  to  resect  the  head 
of  the  pancreas.  Coffey  has  worked  out  a  technic  for  this  operation  by 
transplanting  the  end  of  the  duct  into  the  duodenum  obliquely,  first  incising 
the  duodenum  for  about  an  inch  down  to  the  mucosa,  then  puncturing 
the  mucosa  at  the  end  of  the  incision  distal  from  the  duct  and  fastening 
the  duct  at  this  point  with  a  few  sutures.  The  wound  is  then  closed  in 
such  a  manner  that  the  duct  rests  in  the  length  of  the  incision  solely  on 
the  mucosa  and  the  submucosa,  the  muscular  and  peritoneal  coats  being  closed 
over  it.  In  this  manner  the  mucosa  acts  as  a  valve  and  prevents  back 
pressure  into  the  duct. 

Operations  on  the  pancreas  are  chiefly  for  relief  of  pancreatitis.  Can- 
cer of  the  head  of  the  pancreas  is  usually  inoperable  and  though  Finney  has 
successfully  extirpated  a  growth  involving  the  middle  of  the  pancreas,  can- 
cer is  more  frequent  in  the  head  than  in  any  other  portion  of  this  organ. 
The  operation  to  meet  the  indications  for  excision  of  cancer  of  the  pan- 
creas should  be  arranged  for  excision  of  the  head  of  the  pancreas.  Cof- 
fey* has  worked  out  experimentally  on  dogs  a  very  ingenious  technic  for  this 
excision,  though  the  operation  has  not  yet  been  tried  by  him  on  man.     It 


^Coflfey:     Ann.    Surg.,  December,    1909. 


536 


OPERATIVE    SURGERY 


consists  first  of  extirj^ation  of  the  duodenum  with  the  head  of  the  pan- 
creas and  the  adjoining  tissues,  including  the  end  of  the  common  duct. 
This  would  be  the  type  of  operation  indicated  in  cancer.  The  pancreas 
is  excised  at  a  sufficient  distance  from  the  malignant  growth.  The  cen- 
tral vessels  are  tied.  The  pancreatic  duct  is  divided  so  that  half  an  inch 
or  more  of  the  duct  is  left  protruding  from  the  raw  surface  of  the  cut 
pancreas.  A  loop  of  jejunum  is  then  brought  up  and  sutured  together 
along  its  convex  border  as  though  a  lateral  anastomosis  would  be  made. 
The  bowel  is  incised  in  such  a  way  as  to  throw  the  lumens  of  both  ends 
together  (Fig.  490).  This  makes  the  combined  capacity  of  the  two  limbs 
of  the  loop  sufficient  to  contain  the  stump  of  the  pancreas  without  too  much 


Fig.   490. — ^Excision  of   the   head  of   the  pancreas.     A   loop   of  jejunum   is   clamped,   opened,   and   sutured   in 
the  manner  indicated  to  throw  the  lumens  of  both  loops  into  a  common  .opening   (Coffey). 

tension.  The  peritoneal  surface  at  the  end  of  the  loop  is  inverted  by  mattress 
sutures  which  grasp  the  end  of  the  bowel  and  are  inserted  further  down  in 
the  lumen  so  that  when  pulled  upon  the  end  of  the  combined  loop  is  in- 
verted. The  stump  of  the  pancreas  is  placed  within  this  prepared  receptacle 
made  from  the  combined  loops  of  the  jejunum.  Sutures  are  taken  at  some 
distance  from  the  end  of  the  stump  of  the  pancreas  and  fasten  the  pancreas 
to  the  edge  of  the  opening  of  this  loop.  The  end  of  the  boAvel  is  snugly 
approximated  to  the  pancreas  by  a  collar  suture  which  buries  the  other  su- 
tures that  have  been  taken  from  the  pancreas  to  the  bowel  (Fig.  491).  In  this 
manner  a  considerable  portion  of  the  pancreatic  stump  is  covered.  The  end  of  the 
common  duct  is  implanted  obliquely  into  the  adjoining  distal  stump  of  the 
duodenum  by  making  an  incision  of  an  inch  down  to  the  mucosa  (Fig.  492), 


LIVEE,    GALL   BLADDER,    BILE    TRACTS,    ETC. 


537 


piinetiiring  the  mucosa  at  the  most  distal  point  from  the  common  duct,  and 
after  splitting-  the  common  duct  for  a  short  distance  its  tip  is  inserted 
into  this  pundurc  and  hekl  by  a  suture  which  passes  tlirough  the  wall  of 


Fig.    491. — Diagram    showing   the   head    of    the    pancreas    excised    and   the    stump    of   the    pancreas    implanted 
into    the    loop    of   jejunum   which    has    been   prepared    as    shown    in    Fig.    490    (Coffey). 


Fig.  492. — The  common  bile  duct  is  transplanted  into  the  duodenum  or  into  another  loop  of  jejunum. 
An  incision  is  made -down  to  the  mucosa,  which  is  punctured  at  the  end  of  the  incision  farthest  from  the 
common   duct    (Coffey). 


Fig.    493. — The    tip    of    the    common    duct    is    drawn    through   the   puncture    of    the   mucosa   as    indicated    in 

the   drawing    (Coffey). 


538 


OPERATIVE   SURGERY 


the  duodenum  (Fig.  493).  The  rest  of  the  wound  is  closed  by  intestinal 
sutures  so  that  the  duct  is  partially  protected  from  the  intraintestinal  pressure 
by  the  valve  of  n:i,ucosa  (Figs.  494  and  495).  A  gastroenterostomy  is  done 
in  the  usual  manner. 

Operations  for  pancreatitis  vary  according  to  the  stage  of  the  pancreatitis. 
In  acute  conditions,  Avhere  the  pancreas  is  greatly  swollen,  short  incisions  are 
made  into  the  pancreas  to  relieve  tension  and  are  enlarged  by  inserting 
closed  forceps  and  spreading  the  jaws.     Drainage  with  tubes  and  gauze  is 


Fig.   494. — The  transplantation   of  the  common  duct  is  complete    (Coffey). 

carried  down  to  the  Avound  in  the  pancreas.  If  there  is  free  oozing  the  sup- 
ply of  gauze  drainage  should  be  abundant.  The  approach  to  the  pancreas 
is  usually  best  made  through  the  gastrocolic  omentum.  If  the  stomach  is 
prolapsed  the  pancreas  may  be  approached  above  the  lesser  curvature  of  the 
stomach.     The  necessity  for  incision  in  the  pancreas  must  be  decided  by  the 


Fig.   495. — A  sectional  view   of  the  transplanted   duct,   showing  how  the   mucosa   acts   as   a  valve   to   prevent 
back  pressure  when  the  bowel  is  distended   (Coffey). 

character  of  the  inflammation.  In  subacute  or  in  chronic  pancreatitis  it  is 
not  necessary  to  make  incisions  in  the  pancreas,  but  drainage  should  be  es- 
tablished either  through  the  gall  bladder  or  the  common  duct.  This  relieves 
the  pressure  in  the  common  duct  and  prevents  to  some  extent  the  reflux  of 
bile  into  the  pancreatic  duct  which  has  been  shown  by  Opie  and  others  to 
be  a  very  important  factor  in  the  causation  of  many  cases  of  pancreatitis.  The 
drainage  tube  in  the  common  duct  or  the  gall  bladder  probably  also  acts  as  has 
been  indicated  in  the  chapter  on  Surgical  Drainage  by  reversing  the  lymphatic 
circulation  and  diverting  it  toAvard  the  drainage  tube  in  an  effort  to  extrude 


LIVER,    GALL    BLADDER,    BILE    TRACTS,    ETC.  539 

the  foreign  substance,  which  is  the  tube.  This  may  divert  the  lymphatic  flow 
from  the  pancreas  and  so  cansc  a  withdraAval  of  some  of  the  septic  products 
of  inflammation. 

A  pancreatic  cyst  may  arise  at  any  portion  of  the  pancreas  and  when 
large  sometimes  points  below  the  colon  and  may  simulate  a  tumor  of  the 
lower  abdomen.  It  is  usually  best  treated  by  marsupialization.  An  incision 
is  made  over  the  most  prominent  part  of  the  growth  and  the  relation  of  the 
cyst  to  the  mesentery  of  the  intestine  and  to  the  surrounding  viscera  is  care- 
fully noted.  An  area  of  the  cyst  that  approximates  the  abdominal  wall  is 
selected  and  the  structures  over  it  are  displaced  in  such  a  manner  that  they 
will  be  the  least  disturbed.  Frequently  the  cyst  can  be  approached  through 
the  gastrocolic  omentum.  The  peritoneum  of  this  omentum  is  split  and  the 
cyst  either  sutured  to  the  parietal  peritoneum  or  packed  around  with  gauze 
for  four  or  five  days  until  adhesions  have  formed.  A  cyst  often  forms  as  a  re- 
sult of  pancreatitis  and  is  sometimes  hemorrhagic.  If  a  large  hemorrhagic 
cyst  is  emptied  suddenly  there  may  be  hyperemia  and  further  bleeding 
which  may  necessitate  packing  the  cyst.  This  can  best  be  avoided  by  emp- 
tying the  cyst  gradually  if  its  contents  have  been  proved  by  diagnostic  as- 
piration to  be  bloody.  The  fact  that  pancreatitis  is  apparently  often  caused 
by  inflammatory  disease  of  the  bile  tracts  makes  it  advisable  to  explore  the 
gall  bladder  and  bile  ducts.  If  any  lesion  is  found  the  gall  bladder  or  the 
common  duct  is  opened  and  drained.  This  relieves  the  pressure  within  the 
common  duct  and  prevents  the  flooding  of  the  pancreas  with  bile,  which  is 
often  the  cause  of  pancreatitis. 

Surgery  of  the  spleen  consists  largely  in  splenectomy.  Occasionally  a 
wandering  spleen  is  fixed  in  position,  which  may  be  best  done  by  the  method 
of  Bardenheuer,  by  making  a  pocket  in  the  parietal  peritoneum  and  inserting 
the  lower  portion  of  the  spleen  into  this  pocket.  The  spleen  is  further  fixed 
by  passing  one  stout  suture  through  the  lower  end  of  the  spleen  and  tying 
it  around  the  tenth  rib.  As  a  rule,  when  the  spleen  is  sufficiently  movable  to 
cause  trouble  an  excision  is  the  most  satisfactory  procedure. 

The  technic  of  removal  of  the  spleen  depends  largely  upon  its  size.  Ample 
exposure  is  always  necessary.  The  incision  of  Bevan,  which  has  been  described, 
is  used  on  the  left  side  and  the  gall  bladder  and  liver  are  first  thoroughly  ex- 
plored. If  the  spleen  is  not  greatly  enlarged  and  is  nonadherent  it  is  turned 
into  the  wound  and  the  pedicle  secured  from  behind.  If  the  spleen  is  large 
and  adherent  the  operation  may  be  exceedingly  difficult.  Balfour^  emphasizes 
the  following  points  in  splenectomy:  (1)  The  abdominal  exploration;  (2)  the  dis- 
location of  the  spleen;  (3)  the  use  of  hot  gauze  packs;  (4)  the  protection  of  the 
stomach  and  pancreas  from  injury;  (5)  the  preliminary  ligation  of  adhesions; 
and  (6)  the  treatment  of  the  pedicle  of  the  spleen.  The  first  step  of  the  operation 
after  exploration  consists  in  mobilizing  the  spleen  by  thoroughly  separating  the 
adhesions  between  the  surface  of  the  spleen  and  the  parietal  peritoneum.    If  the 


^Balfour:      Surg.,   Gynec.   &  Obst.,  1916,  xxiii,   1-6. 


540 


OPERATIVE    SURGERY 


adhesions  cannot  be  stripped  satisfactorily  they  should  be  doubly  clamped  and  di- 
vided. If  there  are  many  adhesions  between  the  spleen  and  the  diaphragm 
these  may  be  separated  by  the  finger  or  if  they  are  large  and  vascular  they 
should  be  doubly  clamped  and  divided.  The  spleen  is  dislocated  inward  and 
a  large  pack  of  gauze  wrung  out  of  hot  salt  solution  is  quickly  inserted  into 
the  cavity  formerly  occupied  by  the  spleen.     This  step,  according  to  Balfour, 


Fig.    496. — Exposure    of    the    pedicle    of    tlie    spleen    in    splenectomy.      The    splenic    artery    has    been    doubly 

tied    (Balfour). 


is  very  important  and  serves  not  only  to  control  bleeding,  but  acts  as  a  support 
from  which  point  the  spleen  may  be  more  readily  handled.  This  pack  is  not 
disturbed  until  after  the  completion  of  the  operation.  The  main  pedicle  of 
the  spleen  is  then  brought  into  view  from  its  posterior  surface.  It  must  be 
borne  in  mind  that  the  splenic  veins  are  exceedingly  friable  and  may  be  readily 
injured.  The  dissection  of  the  pedicle  is  made  as  close  to  the  spleen  as 
possible,  so  that  bleeding  from  an  injured  vein  can  be  more  readily  located. 
The  gastrosplenic  attachment  should  be  divided  in  sections  as  close  to  the  spleen 


LIVER,    GALL    BLADDER,    BTI>E    TRACTS,    ETC. 


541 


as  possible,  tlic  division  l)eiiio'  made  between  ligatures.  The  vasa  })revia  are  the 
chief  vessels  here.  The  spleen  is  often  closely  attached  to  the  stomach  and  there 
is  the  danger  of  injuring  the  stomach  if  clamps  are  placed  promiscuously  in 
this  region.  By  doubly  ligating  this  portion  of  the  pedicle  and  then  dividing 
between  ligatures  this  accident  may  be  avoided.  The  exact  relation  of  the 
stomach  is  ascertained  before  placing  the  ligatures.  Careful  dissection  of  any 
retaining  peritoneal  bands  or  fibers  is  made  so  as  further  to  mobilize  the  spleen, 
always  bearing  in  mind  the  very  friable  nature  of  the  splenic  veins.  The  tail 
of  the  pancreas  must  be  recognized.     Its  position  is  often  very  irregular.     It 


Fig.   497. — Another   method   of  treating  the  pedicle   of   the   spleen   when   it   is   difficult   to    expose   the   splenic 

artery    (Balfour) . 


may  actually  be  adherent  to  the  hilus  of  the  spleen,  or  it  may  be  at  such  a  dis- 
tance that  it  is  safely  out  of  range  of  injury.  Sometimes,  according  to  Bal- 
four, the  tail  of  the  pancreas  lies  behind  the  renal  surface  of  the  spleen 
and  sometimes  it  fits  so  closely  into  the  hilus  of  the  spleen  as  to  have  ac- 
quired a  concave  edge;  or  it  may  be  in  front  of  the  splenic  vessels  in  contact 
with  the  stomach.  After  locating  the  tail  of  the  pancreas  it  should,  of  course, 
be  dissected  from  the  spleen  and  the  pedicle  with  great  care.  The  treatment 
of  the  main  pedicle  that  is  left  after  separating  the  npper  portion  of  the  spleen 


542  OPERATIVE    SURGERY 

from  the  stomach  depends  largely  upon  the  location  and  the  arrangement  of  the 
vessels.  If  the  splenic  artery  can  be  readily  demonstrated  it  is  ligated  before 
the  veins  are  tied  (Fig.  496).  If,  however,  this  is  impracticable,  the  spleen  is 
clamped  by  three  pedicle  forceps  at  distances  of  about  half  an  inch  apart  and 
the  pedicle  is  cut  between  the  two  forceps  nearest  the  spleen  (Fig.  497).  A 
ligature  of  catgut  is  applied  to  the  pedicle  after  removing  the  forceps  farthest 
from  the  spleen.  This  ligature  is  placed  in  the  crushed  line  left  after  remov- 
ing the  clamp.  A  second  ligature  of  similar  material  transfixes  the  pedicle 
just  below  the  distal  clamp  and  is  tightened  as  this  clamp  is  removed. 
The  gauze  packing  is  then  carefully  withdrawn  and  any  bleeding  spots 
that  are  left  are  grasped  with  forceps  and  whipped  over  with  catgut  in 
a  small  round  needle.  If  there  is  a  considerable  oozing  surface  that  cannot 
be  readily  controlled  the  packing  may  be  left  in  position. 

W.  J.  Mayo  makes  a  practice  of  closing  the  abdomen  with  the  packing 
in  position  in  the  cases  in  which  the  bleeding  surface  is  extensive,  ve- 
nous in  character  and  difficult  to  control  except  by  packing.  The  sututes 
in  the  abdominal  wall  are  through-and-through  sutures  and  are  tied  in  a 
bow  knot.  Two  or  three  days  later  the  sutures  are  untied,  the  packing  is 
carefully  removed,  and  the  abdominal  wall  is  closed  permanently  with  the 
sutures  that  w^ere  originally  tied  in  a  bow  knot.  This  method  seems  to  lessen 
the  danger  of  infection  which  is  considerable  when  a  large  amount  of  gauze 
is  left  in  position  with  the  ends  of  the  gauze  protruding  through  the  wound. 


CHAPTER  XXV 
OPERATIONS  ON  THE  STOMACH 

Operations  on  the  stomach  may  be  for  correction  of  displacements  or  de- 
formities of  the  stomach  or  for  the  cure  of  nicer  or  malignant  disease.  Oper- 
ations for  displacement  or  ptosis  are  often  done  in  connection  with  ptosis  of  other 
organs,  such  as  the  colon.  The  indications  for  suturing  the  stomach  in  jDosition 
must  be  distinct.  Often  a  prolapsed  stomach  will  empty  satisfactorily,  but  when 
it  does  not,  and  particularly  when  accompanied  by  marked  ptosis  of  the  colon 
and  when  roentgenographic  examination  shows  a  much  delayed  emptying  of  both 
organs,  operation  may  be  indicated.  Many  operations  have  been  devised 
to  correct  this  condition.  Suturing  the  stomach  to  the  abdominal  wall  by 
various  methods  has  been  practiced.  The  hammock  operation  of  Coffey, 
while  really  devised  for  ptosis  of  the  colon,  lifts  the  stomach  upward  and 
forward.  In  Coffey's  hammock  operation  the  gastrocolic  omentum  is  sutured 
to  the  parietal  peritoneum  by  a  series  of  interrupted  sutures  in  a  transverse 
line  as  far  above  the  umbilicus  as  the  sutures  can  be  conveniently  placed. 
This  usually  is  about  half  way  between  the  ensiform  cartilage  and  the  um- 
bilicus. The  chief  objection  to  this  procedure  is  postoperative  pain  from 
pulling  on  the  parietal  peritoneum  though  it  seems  far  better  than  fixing 
the  stomach  wall  to  the  parietal  peritoneum,  or  any  of  the  methods  of  gas- 
troplication  formerly  advocated.  In  the  hammock  operation  the  stomach 
is  permitted  a  considerable  amount  of  freedom  as  it  is  suspended  from 
what  is  really  one  of  its  ligaments  and  the  mobility  of  its  wall  is  but  little 
affected.  The  pain  following  this  operation,  however,  is  not  only  severe  but 
often  embarrasses  respiration.  While  the  pain  either  completely  or  in  a 
large  part  disappears  in  the  course  of  time  it  is  an  annoying  symptom  for 
at  least  a  few  days  after  operation  and  sometimes  for  many  weeks. 

When  the  natural  anatomical  tissues  that  are  intended  for  suspension  of  or- 
gans can  be  utilized  the  effect  is-  more  nearly  to  reproduce  normal  physiologic 
function  than  if  an  unnatural  suspension  or  fixation  is  performed.  The 
main  ligament  that  holds  the  stomach  in  position  is  the  gastrohepatic  omentum. 
This  has  been  utilized  by  Beyea,  whose  operation  of  gastropexy  consists  in 
taking  a  reef  in  the  gastrohepatic  omentum  by  several  rows  of  sutures.  The 
great  objection  to  this  is  that  the  central  part  of  the  gastrohepatic  omentum 
is  the  weakest  and  yet  it  is  usually  opposite  this  central  portion  that  the 
ptosis  of  the  stomach  is  most  pronounced.  Sutures  at  this  point  where  the 
structures  are  weakest  have  the  greatest  strain  to  bear.  Then,  too,  the 
insertion  of  a  series  of  sutures  sufficiently  high  under  the  liver  is  not  al- 
ways an  easy  task  if  they  are  placed  carefully  to  avoid  blood  vessels. 

543 


544 


OPERATIVE   SURGERY 


I  have  sliglitl.v  luodifiod  llie  Boyea  metliod  l)y  using  a  single  pursestring 
suture  of  linen  or  silk,  placed  with  a  small  curved  needle.  This  is  begun 
on  the  lesser  curvature  of  the  stomach  on  the  left  side  of  the  midline,  at  the 
apparent  point  of  beginning  of  ptosis  where  a  firm  bite  is  taken  in  the  gastro- 
hepatie  omentum  just  as  it  enters  the  stomach.  Care  is  taken  to  avoid  the 
vessels.  The  second  bite  of  the  needle  is  in  the  gastrohepatic  omentum 
at  a  point  vertically  above  the  first  bite,  well  up  under  the  liver  and  in 
the  thicker  tissues  in  the  left   of  the   midline,   avoiding   the   large   vessels. 


Fig.   498. — Shortening  the  gastrohepatic   omentum   in  ptosis  of  the   stomach. 

Often  this  operation  is  undertaken  in  very  thin  individuals  and  in  order  to 
grasp  satisfactory  tissue  it  will  be  necessary  to  insert  the  needle  near  some 
large  vessel  where  the  firmer  connective  tissue  forms  a  support  to  the  larger  ves- 
sels. This  can  be  done  so  long  as  the  vessel  can  be  demonstrated  and  is  not 
injured  by  the  needle.  The  suture  is  then  carried  across  the  midline  to  the 
right  side  and  catches  a  bite  in  the  gastrohepatic  omentum  high  up  under 
the  liver.  The  fourth  bite  is  taken  in  the  gastrohepatic  omentum  near  the 
pylorus,  vertically  beloAV  the  third  bite  and  on  the  right  side  of  the  midline. 
It  should  grasp  the  omentum  just  as  it  enters  the  stomach  (Fig.  498).  The 
stomach  is  pushed  well  up  under  the  liver  and  the  suture  is  gradually  tight- 
ened.   This  must  be  done  gentl}'  to  prevent  the  delicate  tissues  from  tearing. 


THE    STOMACH 


545 


Tlio  knot  is  tied  three  times  and  the  ends  are  cut  short.  Usually  there  is 
also  a  i)r()lapse  of  the  transverse  colon.  If  so  the  colon  is  bronfjht  up  in  posi- 
tion l)y  a  series  of  sntnres  of  linen  or  silk,  Miiich  take  a  reef  in  the  gastro- 
colic onientuni  l)v  beG,iiinin<i'  on   the  left  side  and  coin^-  from  the   omentum 


Fig.    499. — The    gastrohepatic    omentum    is    shortened    and    sutures    are    placed    in    the    gastrocolic    omentum. 


just  as  it  leaves  the  stomach  to  the  omentum  just  as  it  reaches  the  colon. 
In  this  manner  the  colon  can  be  brought  up  rather  suugiy  to  the  stomach 
(Figs.  499  and  500).  It  is  important  to  put  the  patient  to  bed  with  the  foot 
of  the  bed  slightly  elevated.  Feeding  through  the  stomach  should  not  be 
begun  for  about  three  days  after  the  operation  and  then  it  should  be  in 
small  amounts,  though  an  ounce  of  water  can  be  given  every  hour.  Small 
rectal  enemas,  not  more  than  three  or  four  ounces,  are  given  every  six  or  eight 
hours. 


546 


OPERATIVE    SURGERY 


This  operation  has  been  veiy  satisfaetor}-.  According  to  Coffey  the  peri- 
toneum is  one  of  the  most  satisfactory  means  of  holding  displaced  organs  in 
position  and  his  operation  for  retroversion  of  the  uterus  was  founded  on 
this  principle,  which  he  has  thoroughly  demonstrated.  If  too  great  strain 
is  not  placed  upon  the  stomacli  until  the  sutured  omentum  has  had  an  oppor- 
tunity to  repair  the  prolapsed  viscera  will  in  all  probability  remain  in  their 
replaced  positions.  This  gives  the  stomach  and  colon  the  advantage  of  normal 
anatomical  support  and  their  physiology  should  be  much  less  interfered  with 
by  such  a  procedure  than  by  introducing  abnormal  ligaments  or  by  fixing  the 
stomach  Avail  to  the  abdominal  wall  so  that  it  is  impossible  for  the  stomach 
to  have  its  physiologic  peristaltic  waves. 


Fig.    500. — The   sutures    in   the    gastrocolic    omentum    are   placed   and    tied. 

In  relaxation  of  the  abdominal  wall,  when  accompanied  by  ptosis,  sup- 
port is  often  satisfactorily  given  by  the  proper  closure  of  an  incision  from 
the  level  of  the  umbilicus  to  the  pubis.  It  is  made  a  little  to  the  right  of  the 
midline.  After  doing  whatever  intraabdoinmal  work  is  necessary  the  peritoneum 
is  closed  by  a  continuous  mattress  suture  that  approximates  the  transversalis 
fascia  and  peritoneum  on  one  side  to  like  structures  on  the  other.  The  sheath 
of  the  rectus  muscle  on  the  left  side  is  opened  and  the  recti  muscles  are 
sutured  together  by  a  continuous  lock  stitch  of  stout  plain  catgut.  The  ante- 
rior sheath  of  both  recti  muscles,  which  consists  of  aponeurosis  of  the  flat  muscles, 
is  undermined  on  both  sides  for  a  space  of  about  three  inches.  The  fat  is  dissected 
from  the  front  of  the  fascia  and  the  left  edge  is  folded  under  the  right  edge 


THE    STOMACH  547 

for  about  three  inches  and  fastened  by  a  series  of  mattress  sutures  of 
tanned  or  chromic  catgut  in  a  similar  manner  to  that  described  in  repair 
of  umbilical  hernia.  These  sutures  are  all  inserted  before  any  one  is  tied. 
They  are  all  di-awn  taut  and  held  by  an  assistant,  while  one  is  tied  at  a 
time.  A  flap,  which  consists  of  the  right  portion  of  the  anterior  part  of 
the  sheath  of  the  recti  muscles  is  overlapped  on  the  left  side  and  fastened  by 
suturing  its  edge  to  the  surface  of  the  aponeurosis  with  a  continuous  lock 
stitch  of  tanned  or  chromic  catgut. 

Coffey  recommends  taking  up  the  slack  in  the  relaxed  abdominal  wall  by 
making  a  long  incision  in  the  general  direction  of  the  McBurney  incision  first  on 
the  right  and  then  on  the  left.  The  aponeurosis  of  the  external  oblique  is  split  and 
overlapped  in  the  manner  just  described  for  overlapping  in  the  midline. 

A  common  cause  of  gastric  surgery  is  ulcer  and  this  is  frequently 
found  at  the  pyloric  end  of  the  stomach.  There  are  many  types  of  op- 
erations done  for  the  relief  of  gastric  ulcer,  but  the  most  common  opera- 
tion for  this  disease  is  gastroenterostomy,  with  or  without  excision  of  the 
ulcer.  The  late  results  of  gastroenterostomy,  however,  leave  much  to  be  de- 
sired. Frank  Smithies,^  a  gastroenterologist,  has  reported  273  patients  on  whom 
this  operation  had  been  done.  His  paper  was  intended  as  a  study  of  the 
function  of  the  stomach  after  gastroenterostomy,  but  the  sidelights  on  the 
efdciency  of  this  operation  as  a  therapeutic  measure  are  illuminating. 

Smithies'  273'  cases  represent  226  patients  operated  on  for  gastric  or 
pyloric  ulcer,  twelve  for  gastric  cancer,  and  thirty-five  for  duodenal  ulcer 
not  involving  the  pylorus.  Of  this  entire  number,  he  reports  only  fifty-seven, 
or  20.9  per  cent,  clinically  complaint  free.  Twenty-eight  of  the  thirty-five 
duodenal  ulcer  patients  had  pain  or  distress,  and  many  of  this  number  had 
other  symptoms,  such  as  gas,  nausea,  vomiting,  or  eructation.  As  the  total 
num,ber  of  cases,  however,  is  made  up  of  (1)  patients  requested  to  return  for 
examination  regardless  of  their  condition,  and  (2)  patients  who  came  volun- 
tarily because  they  were  having  trouble,  the  percentage  of  cures  represented 
is  too  low.  In  reply  to  a  request,  Smithies  has  written  me  under  date  of  April 
10,  1919,  that  about  65  per  cent  of  273  patients  (177)  returned  for  examination 
at  his  request.  Percentage  based  on  this  number  (177)  would  be  unduly 
favorable  because  these  cases  were  selected  apparently  arbitrarily  from  a 
large  number  of  stomach  patients  on  whom  operation  had  been  performed 
and  who  had  been  observed  by  Smithies  (2,360)  and  would  not  include  those 
patients  who  came  voluntarily  because  of  trouble.  Making  all  allowances 
for  this  latter  group,  which  constitutes  about  one-third  of  the  total  number, 
we  still  have  a  percentage  of  complaint  free  patients  that  is  very  low  (much 
below  50  per  cent)  both  for  gastric  and  for  duodenal  ulcer  patients  on  whom 
gastroenterostomy  had  been  done. 

Balfour-  says  that  although  surgery  gives  permanent  relief  in  a  higher  per- 
centage of  cases  of   gastric  ulcer  with   less  risk   than  any   other   therapeutic 


^Smithies,   Frank:      Surg.,   Gynec.   &  Obst.,   March,   1918,   xxvi,   p.  27S,   et  seq. 
-Balfour:     Surg.,  Gynec.  &  Obst.,  xxiv,  p.  731,  et    seq. 


548  OPERATIVE    SURGERY 

measure,  surgical  treatment  of  gastric  ulcer  may  be  made  more  efficient.  He 
reports  285  eases  of  gastric  ulcer  that  have  been  operated  upon  at  the  Mayo 
Clinic  with  55.7  per  cent  complaint  free  cases.  The  rest  are  classified  as 
' '  greatly  improved, "  "  improved, "  and  "  unimproved. ' '  These  results  reported 
by  Balfour  and  by  Smithies  certainly  cannot  be  considered  satisfactory  so  far 
as  curing  the  patients  is  concerned. 

It  is  obvious  that  gastroenterostomy  for  duodenal  or  gastric  ulcer  does 
not  restore  the  stomach  to  its  normal  physiologic  condition.  The  clinical  cures 
following  this  operation  have  been  variously  explained.  Some  have  said  that 
it  is  a  gravity  drainage  operation,  and  yet  in  draining  other  hollow  muscular 
viscera  we  do  not  open  at  the  lowest  point.  The  gall  bladder  and  the  urinary 
bladder  are  drained  from  the  part  opposite  the  most  dependent  portion,  and 
an  enterostomy  is  done  on  the  loop  of  intestine  nearest  the  obstruction  and 
not  on  the  loop  deepest  in  the  pelvis;  for  we  know  that  normal  contraction 
or  peristalsis  will  keep  the  bladder  or  bowel  empty  if  an  opening  is  made. 
From  time  immemorial  the  current  of  pressure  and  the  peristaltic  rhythm  of 
the  stomach  have  been  focused  on  the  pylorus,  and  not  on  the  so-called  lowest 
point  in  the  stomach.  Besides,  there  is  no  one  portion  of  a  mobile  muscular 
organ,  such  as  the  stomach,  that  is  always  the  lowest  point.  This  and 
other  disadvantages  of  gastroenterostomy  have  been  admirably  demonstrated 
by  Cannon  and  Blake.'  It  has  been  affirmed  that  gastroenterostomy  cures  by 
short-circuiting  the  course  of  food  and  so  resting  the  ulcer;  and  also  that  it 
cures  by  lessening  the  acidity  of  the  gastric  juice.  The  roentgen  ray  has 
shown  that  unless  the  pylorus  is  closed  some  food  usually  continues  to  go 
by  this  route  and  pyloric  closure  is  not  often  i)ermanent  unless  a  resection 
is  done. 

Lennander's  statement*  that  the  stomach  is  without  sensory  nerve  sup- 
ply for  pain  has  been  apparently  disproved.  Other  investigations'  seem 
to  have  shown  that  the  stomach  has  a  limited  supply  of  nerves  that  conduct 
pain.  These  nerves  terminate  in  the  muscular  coat  of  the  stomach,  and  do 
not  reacb  the  mucosa.  The  pains  that  come  on  with  such  clocklike  regularity 
after  meals  in  duodenal  or  gastric  ulcer  are  not  caused  by  acid  erosion 
of  the  ulcer  by  the  hyperacid  gastric  juice,  as  was  formerly  believed,  but 
are  due  to  the  pressure  of  peristalsis  on  these  gastric  nerves,  which  are 
made  unusually  sensitive  by  the  inflammation  of  the  ulcer.  Consequently, 
they  register  impulses  of  pain  from  the  pressure  of  peristalsis  which  in 
a  normal  physiologic  condition  they  would  not  register.  The  gastric  juice 
has  nothing  to  do  with  the  pain  except  so  far  as  it  excites  peristalsis. 

Gastroenterostomy  probably  relieves  the  pain  from  a  duodenal  or  gas- 
tric ulcer  by  facilitating  the  emptying  of  the  stomach  and  thus  lessening 
peristalsis.    It  is  also  probable,  as  has  been  claimed  by  others,  that  a  certain 


'Cannon  and  Blake:     Ann.    Surg.,  May,   1905,  xli,  686-711. 

^Lennander,  K.   G.:     Jour.  Am.  Med.   Assn.,   Sept.   7,   1907,   xlix,   836. 

^Kast,  L,.,  and  Meltzer,  S.  J.:  Sensibility  of  Abdominal  Organs  and  the  Influence  on  It  of  Injec- 
tions of  Cocain,  Med.  Rec,  New  York,  December,  1906,  Ixx,  1017.  Ritter,  C:  Sensibilitat  der  liauch- 
organe,  Zenlralbl.  f.  Chir.,  May  16,   1908,  xxxv,  609. 


THE    STOMACH  549 

aiiiouiit  of  jejunal  contents  regurgitates  into  the  stomach  and  decreases  the 
acidity  of  the  gastric  juice.  Tliis  affects  the  pain,  however,  by  diminishing  the 
peristalsis  because,  as  has  been  explained,  the  bad  effect  of  a  hyperacid  gas- 
tric juice  on  an  ulcer  is  not  due  to  any  intrinsic  action  of  the  gastric  juice 
because  of  acidity,  but  it  is  because  the  excessive  acidity  stimulates  the  peris- 
talsis and  excessive  peristalsis  not  only  produces  pain  but  prevents  healing 
of  the  ulcer,  just  as  excessive  action  of  the  sphincter  ani  prevents  healing  of 
an  ulcer  Avithin  its  grasp. 

The  jejunum  is  physiologically  accustomed  to  alkaline  contents.  The 
acidity  of  the  gastric  juice  is  neutralized  in  the  first  portion  of  the  duodenum, 
and  when  the  current  of  food  reaches  the  jejunum  it  is  normally  always 
distinctly  alkaline.  When  the  acid  contents  of  the  stomach  are  dumped  di- 
rectly into  the  jejunum  as  after  a  gastroenterostomy,  it  is  natural  to  expect 
some  reaction  on  the  part  of  the  jejunum  against  this  change  from  an  alka- 
line to  an  acid  medium.  If  the  urine  continued  alkaline  for  several  days 
there  Avould  probably  be  a  cystitis  and  the  best  method  of  curing  the  cystitis 
is  to  make  the  urine  acid  and  so  let  the  bladder  contain  an  acid  medium  for 
which  it  is  physiologically  fitted.  No  matter  how  much  of  the  contents  of 
the  jejunum  is  regurgitated  into  the  stomach  there  is  probably  not  enough 
to  render  the  stomach  contents  constantly  alkaline.  In  large  clinics  jeju- 
nal or  gastro jejunal  ulcers  are  reported  as  a  late  complication  in  from  two 
to  five  per  cent  of  the  total  number  of  gastroenterostomies.  It  seems 
probable  that  for  every  jejunal  ulcer  there  must  be  many  more  instances 
of  some  reaction  to  the  acid  medium  on  the  part  of  the  jejunum,  such  as 
hyperemia,  that  will  be  sufficient  to  produce  symptoms  though  the  symp- 
toms may  not  be  of  a  very  severe  nature.  It  is  likely  that  symptoms 
caused  in  this  way  account  for  the  small  percentage  of  complaint-free  cases 
found  in  carefully  traced  gastroenterostomies.  These  complaints  often  do 
not  occur  until  several  months  or  years  after  the  operation  when  the  jeju- 
num is  no  longer  able  to  withstand  the  continued  irritation  of  the  acid. 

The  dangers  of  vicious  circle,  jejunal  ulcer,  volvulus,  or  hernia  into  the 
lesser  j)eritoneal  cavity,  though  not  great,  exist  Avhen  a  gastroenterostomy  is 
done  and  are  not  present  after  operations  on  the  pylorus.  It  must  be  re- 
membered that  jejunal  ulcer  following  gastroenterostomy  is  caused  by  this 
operation,  for  I  know  of  no  reported  jejunal  ulcer  following  any  form  of  py- 
loroplasty. This  alone  is  a  great  burden  for  gastroenterostomy  to  carry. 
So  great  an  authority  on  stomach  surgery  as  W.  J.  Mayo"  says  he  treats  jeju- 
nal ulcer  following  gastroenterostomy  by  disconnecting  the  gastroenterostomy 
and  doing  Finney's  pyloroplasty.  The  advantages  of  the  prophylactic  treat- 
ment for  jejiinal  ulcer  are  obvious. 

The  pyloroplasty  of  Finney  consists  of  a  horseshoe-shaped  incision  Avith 
its  center  at  the  pylorus,  one  limb  extending  doAvn  on  the  mobilized  duode- 
num and  the  other  on  the  stomach  near  the  greater  cmwature   (Fig.   501). 


•'Mayo,   W.   J.:      Tour.   Am.   Med.   Assn.,  July   24,    1920,   p.   221. 


550 


OPERATIVE   SURGERY 


These  limbs  of  the  incision  are  united  by  snturing  the  posterior  margin  of 
the  wound  in  the  duodenum  to  the  posterior  margin  of  the  wound  in  the 
stomach  and  the  anterior  margin  of  the  wound  in  the  duodenum  to  the  anterior 
margin  of  the  wound  in  the  stomach  (Fig.  502).  Many  of  the  objections  that 
apply  to  gastroenterostomy  do  not  obtain  here  as  the  operation  is   done  at 


Fig.    501. — Lines   of   incision   for   pyloroplasty    of   Finney. 

the  normal  physiologic  outlet  of  food  from  the  stomach.     The  results,  as  re- 
ported by  Finney  and  Friedenwald,  are  excellent. 

Finney's  operation,  while  a  distinct  improvement  on  gastroenterostomy, 
is  not  free  from  objections.  It  seems  to  have  been  conceived  partly  with  the 
idea  of  making  it  a  gravity  drainage  operation,  when,  as  already  pointed 


Fig.    502. — The   posterior    row    of    sutures    has   been    placed    and    tied,    and    the    margins    of    the    wound    are 
being  united  with  a  continuous  lock  stitch.     (Finney.) 


THE    STOMACH  551 

out,  drainao'e  of  a  liol1(n\-  imiscular  organ,  such  as  the  ])ladder  or  bowel,  does 
not  have  to  be  from  the  lowest  point  in  order  to  be  effective.  Mobilization  of  the 
duodennm,  whicli  is  necessary  for  this  operation,  may  be  quite  difficult  and, 
according-  to  Finney,  where  numerous  adhesions  exist,  his  operation  often 
cannot  be  done.  The  incision  is  made  near  the  greater  curvature  of  the  stom- 
ach, where  the  vessels  are  large.  The  pylorus  is  divided  in  such  a  manner 
that  it  cannot  reunite,  and  its  sphincteric  action  would  seem  to  be  perma- 
nently impaired.  If  there  is  cicatricial  contraction  at  the  pj^orus,  scar  tis- 
sue must  be  sutured  to  scar  tissue,  for  the  apex  of  both  the  posterior  and  the 
anterior  margins  of  the  sutured  wound  are  at  the  pylorus. 

The  operation  of  Heineke-Mikulicz  is  usually  supposed  to  be  a  straight 
incision  with  its  center  at  the  pylorus  or  at  the  point  of  constriction,  the  in- 
cision being  sewed  up  transversely.  Such  is  the  description  of  this  operation 
as  it  appears  in  many  textbooks.'^  Binnie^  gives  a  description  of  this  operation 
that  resembles  somcAvhat  the  Finney  operation. 

The  Heineke-Mikulicz  operation  in  its  usual  conception  as  a  straight 
incision  with  its  center  at  the  point  of  constriction  or  at  the  pylorus,  the 
incision  being  sewed  up  transversely,  finds  but  few  advocates.  Grey  Tur- 
ner^ reports  a  small  series  of  cases  done  by  this  method  in  which  the  re- 
sults are  quite  satisfactory.  As  a  rule,  however,  these  objections  are  made 
to  the  Heineke-Mikulicz  as  ordinarily  performed:  (1)  It  creates  a  jjouch 
with  a  slight  constriction  on  the  stomach  side  and  on  the  duodenal  side.  Half 
of  this  pouch  is  made  of  the  duodenum  whose  walls  are  much  Aveaker  than 
the  walls  of  the  stomach  and  it  may  be  difficult  to  empty  such  a  pouch.  (2) 
The  incision  cannot  be  made  very  long  because  it  would  extend  too  far  into 
the  duodenum,  Avhich  Avould  have  to  be  mobilized,  and  even  then  the  tension 
of  the  sutures  on  the  thin  duodenal  Avail  Avould  be  too  great.  (3)  When 
stenosis  exists,  each  end  of  the  sutured  AA^ound  consists  of  scar  tissue  which 
is  sutured  to  scar  tissue,  for  the  center  of  the  incision  is  at  the  point  of  con- 
striction. (4)  There  is  a  tendency  in  healing  for  the  pylorus  to  be  draAvn  up 
high  under  the  liver. 

There  is  one  part  of  the  body  in  Avhich  an  ulcer  in  the  region  of  a  sphincter 
has  been  the  object  of  surgical  observation  since  the  earliest  times  of  recorded 
surgery,  and  the  treatment  of  this  condition  has  become  satisfactorily  stand- 
ardized. This  is  ulcer  or  fissure  in  ano.  The  analogv  betAveen  an  ulcer  in 
ano  and  a  duodenal  or  pyloric  ulcer  of  the  stomach  AA'hich  is  in  the  region  of 
the  pyloric  sphincter  is  striking.  We  knoAV  that  the  ulcer  in  ano  does  not 
heal  readily  because  of  the  almost  continuous  action  of  the  sphincter  ani, 
AA-hich  alternately  compresses  or  relaxes  the  tissues  in  its  neighborhood,  and 
that  in  order  to  cure  it  Ave  must  employ  the  principle  of  physiologic  rest  and 
paralyze  the  sphincter  temporarily,  and  at  the  same  time  excise  or  cauterize 


■P.rvaiit:      Operative   Surgery,   I'^OS,  ii,   943. 

Dacosta:     Modern    Surgery,   Philadelphia,    1918,   AA^   B.    Saunders   Co.,    ed.    7,    p.    1081. 

American  Text-P>ook  of   Surgery,  ed.   4.   p.   790. 

AA'arbasse:      Surgical   Treatment,    Philadelphia,    1918,   AV.   B.    Saunders   Co.,   ii,   p.    738. 
^Binnie:     Operative   Surgery,  ed.   7,   p.  385. 
^iTurner,   G:      Surg.,   Gynec.  S:   Obst.,  June,   1912,   xiv,   S37. 


552 


OPERATIVE    SrRGERY 


the  ulcer.  In  tins  nianiier  we  remove  the  pathologic  condition  and  institute 
rest  for  these  tissues.  We  Avould  not  think  of  treating  a  fissure  in  ano  by 
doing  a  colostomy  and  side-switching  the  fecal  contents,  particularly  if  the 
colostomy  permitted  a  small  amount  of  fecal  matter  to  continue  to  pass 
through  the  anus;  and  yet  in  performing  a  gastroenterostomy  for  the  cure 
of  pjdoric  or  duodenal  ulcer  we  are  practically  doing  just  this  very  thing.  By 
using  the  well-known  surgical  principles  that  have  been  established  for  years 
for  the  treatment  of  fissure  in  ano,  namely,  temporary  paralysis  of  the 
sphincter  and  excision  or  cauterization  of  the  ulcer,  we  can  cure  practically 
100  per  cent  of  such  cases.  If,  then,  the  ulcer  in  the  duodenum  or  pylorus 
is  not  cancerous  and  is  the  only  pathologic  lesion,  have  we  not  a  right  to  ex- 
pect as  good  results  here,  so  far  as  ultimate  cure  is  r-onconied.  by  excision  of 


Fig.^  503. — Liiu-s  <>i  iinisuui  tor  the  author's  pi'loroplasty.  If  the  ulcer  is  in  the  midline,  the  incision  is 
carried   to   the   ulcer,   which    is   then   excised,   and   the   excision    forms   the    duodenal   portion    of   the    incision. 

this  ulcer  and  temporary  paralysis  of  the  sphincter  muscles,  as  has  been 
obtained  since  the  early  days  of  surgery  by  similar  treatment  of  an  ulcer  within 
the  region  of  the  sphincter  ani?  The  operation  here  proposed  has  been  con- 
ceived on  these  principles,  and  an  effort  has  been  made  to  carry  them  out  as 
far  as  possible,  at  the  same  time  avoiding  the  objections  that  have  been  noted 
to  other  t3'pes  of  pyloroplasty.     The  steps  of  the  operation  are: 

1.  The  upper  portion  of  the  duodenum  and  the  pyloric  end  of  the  stomach 
are  exposed  through  an  ample  abdominal  incision,  preferably  the  Bevan  in- 
cision. A  point  is  selected  on  the  stomach  not  less  than  two  inches  from  the 
pylorus  and  midAvay  between  the  greater  and  lesser  curvatures,  and  is  grasped 
with  Allis  forceps  or  fixed  with  a  suture.  The  stomach  and  duodenum  are 
then  surrounded  with  moist  gauze  (Fig.  503). 

2.  The  length  of  the  incision  for  the  pyloroplasty  depends  upon  the  loca- 


THE    STOMACH 


553 


tion  of  the  iiUhm',  hut  the  sloiiuicli  portion  of  the  incision  must  always  be  at 
least  tAviec  as  loiii>'  as  the  duodenal  portion.  If  the  nleer  is  in  the  duodenum 
and  is  more  than  threo-fonrtlis  of  an  inch  from  the  i)ylorns,  pyloroplasty  should 
not  be  done,  but  the  ulcer  should  be  excised  with  an  elliptical  iiieision  transversely 
across  the  duodenum,  accordino'  to  the  method  of  E.  S.  Judd  of  the  Mayo  Clinic, 
and  the  incision  is  closed  with  two  rows  of  sutures  placed  transversely  so  that 
there  will  be  no  constriction  of  the  lumen  of  the  duodenum.  When  an  ulcer 
in  the  duodenum  is  not  farther  from  the  pylorus  than  three-fourths  of  an 
inch,  pyloroplasty  gives  most  satisfactory  results.  When  the  ulcer  is  in  the 
stomach  at  some  distance  from  the  pylorus,  pyloroplasty  should  be  done  in- 
stead of  gastroenterostomy,  and  here  the  total  length  of  the  incision  need  be 
no  longer  than  two  inches,  with  one-half  inch  of  the  incision  in  the  duodenum 


Fig.  504. — The  ra*io  of  ihe  incision  should  always  be  at  least  two  parts  in  the  stomach  to  one  in 
the  duodenum.  The  incision  is  first  carried  down  through  the  stomach  and  then  the  duodenum  is  opened. 
The  vessels   are  tied   and   the  ulcer   is   exposed. 


and  one  and  one-half  inches  in  the  stomach.  For  many  ulcers  near  the  py- 
lorus a  two  inch  incision  is  sufficiently  long.  A  short  incision,  of  course,  makes 
the  suturing  easier  and  the  operation  can  be  completed  more  quickly.  The 
incision  is  carried  from  the  previously  fixed  point  on  the  stomach  to  the  py- 
lorus, using  a  sharp  knife  and  preferably  cutting  down  to  the  mucosa  and 
clamping  and  tying  the  vessels  before  opening  the  mucosa.  When  the  mucosa 
is  opened,  the  pylorus  is  divided  and  the  ulcer,  which  is  exposed,  is  removed. 
It  can  thus  be  accurately  circumscribed  by  an  incision  and  no  more  healthy  mu- 
cosa is  sacrificed  than  is  necessary. 

3.  If  there  is  a  tendency  for  the  gastroduodenal  contents  to  regurgitate 
into  the  wound,  a  moist  gauze  pack  is  gently  introduced  into  the  stomach  and 
a  small  strip  of  moist  gauze  is  carefully  placed  in  the  duodenum.    They  should 


554 


OPERATIVE    SURGERY 


be  noted  by  the  nurse,  so  there  ^vill  be  no  possibility  of  overlooking  tlie  gauze 
when  the  wound  is  being  closed. 

4.  If  the  ulcer  is  in  the  posterior  wall  of  the  duodenum  or  pylorus,  the 
wound  is  retracted,  the  ulcer  exposed  and  excised,  the  deeper  structures  are 

sutured  with  tanned  or  chromic  catgut,  and  the  mucosa  is  gently  approximated 


Fig'.    505. — If  there  is  marked   stenosis   with  pocket  formation   on  the    duodenal   side,   the   cicatricial   band   is 

divided   with  a   superficial   incision. 


Fig.    506. — The   posterior   part   of    the   pylorus   is    reconstructed    with    sutures    as    sliown    in    the    illustration, 
after   cicatricial   bands   have  been   divided   or   stretched. 


by  a  continuous  suture.  The  suture  in  the  mucosa  must  not  be  tight,  as  this 
might  cause  necrosis  of  the  mucosa  and  spread  the  ulcer.  If  there  is  an  old 
contraction  resulting  in  pockets,  the  mucosa  and  the  contracting  band  should 
be  divided  and  the  mucosa  sutured  transversely  to  the  incision.  To  avoid 
hemorrhage,  the  incision  that  relieves  the  contracting  band  should  be  short 
and  should  divide  only  the  superficial  part  of  the  band.  The  neglect  of  this 
precaution  resulted  in  a  fatal  secondary  hemorrhage  (Figs.  505  and  506). 


THE    STOMACH 


555 


Fig.  507-A. — ^A  tractor  or  guy  suture  is  placed  from  one   extremity   of  the  suture  to   the   other. 


Fig.    S07-B. — A    second    tractor   suture   is    placed    about    one-half    inch   above    the    first.      The    second    is    tied 

before  the  first  in  order  to   relieve  the  strain. 


556 


OPERATIVE    SURGERY 


5.  The  ulcer  Jiaving  been  removed  or  pockets  and  contractions  remedied, 
the  ends  of  the  incision  are  ai^proximated  by  a  tanned  or  chromic  catgut  suture 
(Fig*.  507A).  A  second  suture  of  similar  material  is  placed  half  an  inch  above 
this  middle  suture  and  renders  suturing  the  upper  half  of  the  incision  easier. 
There  is  a  tendency  for  a  duodenal  fold  to  form  if  these  sutures  are  too  far 
apart.  Both  are  tied  and  their  ends  left  long  to  facilitate  suturing  and  to 
hold  up  the  edges  of  the  wound  and  so  prevent  injury  to  the  posterior  portion 
of  the  pylorus  while  suturing.     (Fig.  5075.)     A  No.  1  tanned  or  chromic  catgut 


Fig.    SOS. — The    mucosa    is    united   with    a   continuous    lock    stitch    of    tanned    catgut.      No    effort    is    made   to 
secure   inversion   but   the   mucosa   is   merely   approximated   to   prevent   leakage. 


suture  is  then  started  in  the  mucosa  at  the  lowest  portion  of  the  wound,  which  is 
in  the  stomach  wall.  It  is  tied,  the  short  end  clamped,  and  the  mucous  membrane 
is  united  by  a  lock  stitch  which  barely  approximates  the  mucosa  and  ends  at 
the  upper  portion  of  the  incision,  which  is  also  in  the  stomach  wall.  Before 
completing  this  suture  any  gauze  packing  in  the  duodenum  or  stomach  is 
removed.  The  suture  is  tied  at  the  upper  portion  of  the  wound  and  the  ends 
are  left  long  and  clamped  (Fig.  508). 

6.  A  second  row  of  sutures,  consisting  of  the  same  kind  of  catgut,  in  a 
curved  round  needle,  is  inserted,  uniting  the  muscular  and  peritoneal  coats. 


THE    STOMACH 


557 


This  is  a  simple  continuous  stitch  that  approximates  the  edges  of  the  perito- 
neal and  musenliir  coats  as  a  skin  wound  would  be  sutured.  No  attempt  is 
made  in  this  row  to  invert  the  edges  of  the  wound  as  this  would  make  too  great 
a  bulk  of  tissues  along  the  suture  line.  Only  enough  tissue  is  included  in  the 
sutures  to  secure  a  firm  hold.  The  long  ends  of  the  previous  row  are  cut  short 
(Fig.  509). 

7.  A  third  row  of  sutures  of  fine  tanned  or  chromic  catgut  is  placed,  but  the 
gauze  around  the  stomach  and  duodenum  should  be  removed  before  this  third 
row  is  begun,  as  gauze  packing  hinders  the  approximation  of  the  peritoneum. 


m 

~^    "5 

1 

L 

\f 

H| 

m 

"y 

m 

•~\ 

R^', 

-f^' 

i> 

"P-i* 

^- 

■■^ 

~^\ 

^^      ~N 

1 

' 

Fig.    509. — The    tractor   sutures    have    l^een    cut.      The    edges    of    the    peritoneal    and    muscular    coats    are   ap- 
proximated with  a  continuous   suture   without   any   attempt   to    invert   the   edges. 

This  row  includes  the  peritoneal  and  muscular  coats  and  buries  the  first  and 
the  second  rows  of  sutures  completely.  It  invests  the  two  ends  of  the  in- 
cision as  teats.  This  is  a  continuous  mattress  or  right-angle  stitch.  If  the 
middle  of  the  wound  has  not  been  satisfactorily  approximated  one  or  two 
mattress  sutures  of  fine  catgut  should  be  placed  there  (Fig.  510). 

8.  A  portion  of  the  gastrocolic  omentum,  or  else  the  right  edge  of  the 
great  omentum,  can  be  brought  up  over  the  line  of  sutures  without  tension. 
It  is  fastened  here  with  interrupted  stitches  of  fine  catgut.  Care  should  be 
taken  that  it  barely  covers  the  upper  end  of  the  sutured  wound  and  that  it 


558 


OPERATIVE   SURGERY 


/ 

./ 

'■■     /V 

A 

\_ 

^21 

/ 

i 

^ 
j 

Fig.    510. The   third    i  n\\    of    Mitiins    is    placed   as   a   continuous   right   angle   suture    which   buries   the 

other   two'  rows.      It   is   begun    by    surrounding   the    lower    extremity,    which    forms   a   teat,    as   a    pursestring 
suture.      This    is    inverted   as    the   first    knot    is   tied.      By    a   similar   procedure    the    upper    teat    is    inverted. 


Fig.  511. — A  tag  of  gastrocolic  omentum  or  of  the  great  omentum  is  brought  up  over  the  suture 
line  and  fastened  with  a  few  catgut  sutures.  This  not  only  protects  the  sutures,  but  tends  to  prevent  the 
drawing  up  of  the  pylorus  under  the  liver  as  healing  occurs.  Insert  A  shows  the  contour  of  the  stomach  as 
it  is  changed  by  this  pyloroplasty. 


THE    STOMACH  559 

is  not  fastened  to  the  gastroliepatie  omentum,  as  this  might  result  in  too  com- 
plete a  surrounding'  of  the  pyloric  end  of  the  stomach  (Fig.  511). 

9.  If  the  ulcer  is  not  in  the  duodenum  or  the  pyloric  region,  the  operation, 
as  just  described,  may  be  done  to  relieve  the  spasm  of  the  pylorus  and  the 
ulcer  then  excised,  or  cauterized,  as  advocated  by  Balfour,  through  another 
gastric  incision. 

Where  exposure  is  difficult  or  where  the  ulcer  is  in  the  cardiac  portion 
of  the  stomach,  a  shorter  incision  in  the  stomach  and  duodenum  can  be  effec- 
tively used.  An  inch  and  a  half  is  often  sufficient,  but  the  ratio  of  one  part 
of  the  incision  in  the  duodenum  to  two  parts  in  the  stomach  must  always  be 
observed. 

The  advantages  of  this  operation  are: 

1.  It  removes  the  obstruction  and  the  pathologic  condition,  and  permits 
the  normal  resumption  of  the  stomach  function. 

2.  The  ends  of  the  sutured  incision  are  within  the  stomach  wall.  The 
ratio  of  the  incision  should  never  be  less  than  two  parts  in  the  stomach  to  one 
in  the  duodenum.  Usually  two  inches  in  the  stomach  and  one  in  the  duodenum 
are  sufficient.  The  anterior  stomach  wall  in  the  midline  can  readily  be  pulled 
over  to  the  first  inch  of  the  duodenum.  In  the  Heineke-Mikulicz  operation, 
and  also  in  the  upper  part  of  the  Finney  operation,  the  ends  of  the  sutured 
incision  are  in  the  scar  tissue  at  the  pylorus,  while  in  this  operation  the  ends 
of  the  sutured  incision  are  within  the  healthy  stomach  wall,  and  the  scar  tis- 
sue that  may  remain  about  the  pylorus  is  approximated,  not  to  other  scar 
tissue,  but  to  healthy  stomach  wall.  Consequently,  union  should  be  more  sat- 
isfactory than  where  scar  tissue  is  opposed  to  scar  tissue,  as  in  the  other  two 
types  of  pyloroplasty. 

3'.  There  is  no  pouch  formation  as  in  the  Ileineke-Mikulicz  operation,  in 
which  the  center  of  the  incision  is  at  the  pylorus.  The  operation  merely 
changes  the  shape  of  the  pjdoric  end  of  the  stomach  from  a  funnel  with  grad- 
ually approaching  walls  to  a  rectangle  that  empties  into  a  funnel  with  a  more 
obtuse  angle  (Fig.  511-a). 

4.  The  parts  to  be  put  at  rest  are  the  parts  most  concerned  in  contraction 
and  relaxation,  which  are  the  pylorus  and  the  adjacent  portion  of  the  stomach. 
By  making  the  incision  from  the  duodenum  about  2  inches  into  the  stomach, 
this  is  effected.    A  long  incision  into  the  duodenum  does  not  help  in  any  way. 

5.  The  function  of  the  pylorus  and  the  pyloric  end  of  the  stomach  is  not 
permanently  destroyed.  The  stomach  wall  that  is  brought  over  acts  as  a  link 
between  the  ends  of  the  pyloric  sphincter  and,  in  the  course  of  time  (usually 
a  few  weeks),  the  sphincter  resumes  its  action,  though,  because  it  has  been 
enlarged,  it  cannot  become  spastic  as  it  was  before  the  operation  (Fig.  512). 

6.  The  operation  is  simpler  than  the  Finney  operation,  in  which  the  duo- 
denum has  to  be  mobilized  and  the  posterior  and  the  anterior  margins  of  the 
wound  must  be  sutured  separateh\ 

There  is  a  superficial  resemblance  between  this  operation  and  the  Heineke- 
Mikulicz,  because  in  both  operations  the  pylorus  is  divided  and  in  both  the 


5G0 


OPERATIVE    SURGERY 


incision  is  approximately  straiglit.  Here,  however,  the  resemblance  ceases, 
and  the  cliit'erences  become  marked,  for,  unlike  the  lleineke-Mikulicz,  the 
operation  descriljed  was  conceived  on  the  principle  of  giving  temporary  phys- 
iologic rest  to  tissues  in  the  pylorus  and  the  pyloric  end  of  the  stomach ;  the 
incision  is  longer  than  in  the  Ileineke-^Mikulicz  operation ;  it  is  dilferently 
placed;  it  extends  not  more  than  one  inch  into  the  duodenum  and  the  stomach 
incision  is  always  at  least  double  the  duodenal  incision ;  it  can  be  considerably 
prolonged  at  the  stomach  end ;  it  gives  an  excellent  view  of  the  pyloric  end  of 
the  stomach;  it  requires  a  rather  definite  technic  to  be  closed  satisfactorily;  it 
does  not  form  a  pouch  with  a  constriction  fore  and  aft;  it  does  not  approxi- 
mate scar  tissue  to  scar  tissue ;  and  an  essential  part  of  the  operation  is  the 
removing  or  remedying  of  the  pathologic  condition  by  excising  the  ulcer,  ob- 
literating pockets,  or  incising  constricting  bands.  In  addition,  the  reenforcing 
with  omentum  adds  security  to  the  sutures,  prevents  adhesions  to  surrounding 


Fig.  512. — A  roentgenogram  of  a  patient.  Miss  E.  D.  H.,  taken  four  and  one-half  months  after 
this  pyloroplasty  was  done.  The  patient  had  a  typical  duodenal  ulcer  with  marked  ptosis.  There  were 
no  adhesions.  The  pylorus  as  shown  is  functioning  normally,  with  a  perfect  duodenal  cap.  The  pylorus 
is  slightly  larger  than  normal.  The  structure  and  function  of  the  stomach  have  not  been  materially  altered 
by  this  operation.      The  patient   while  using   an   abdominal    support  is   complaint    free. 


tissues,  and  counteracts  the  tendency  for  the  pylorus  to  become  fixed  high  up 
under  the  liver,  which  sometimes  occurs  after  the  Heineke-Mikulicz  operation. 
The  postoperative  treatment  is  about  the  same  as  that  employed  for  gas- 
troenterostomy. If  there  is  uny  vomiting  or  marked  discomfort,  the  stomach 
should  be  promptly  washed  out  under  low  pressure,  not  more  than  a  pint  of 
fluid  being-  used  at  a  time.  Gastric  lavage  should  be  resorted  to  without  hes- 
itation and  may  be  needed  oftener  than  after  gastroenterostomy.  The  head  of 
the  bed  is  elevated  from  12  to  18  inches,  and  the  patient  is  given  one-half 
ounce  of  hot  water  every  hour  for  the  first  twenty-four  hours  and  after  that 
2  ounces  of  hot  water  CA'^ery  hour  for  tAventy-four  hours.  Enemas  of  6  ounces 
of  physiologic  sodium  chlorid  solution  Avith  one-half  ounce  of  glucose  and 
1  dram  of  sodium  bicarbonate  are  giA^en  cA'cry  six  hours  for  the  first  tAvo  da3'S. 
At  the  end  of  forty-eight  hours  a  small  amount  of  liquid  nourishment  is  com- 


THE    STOMACH 


561 


menced.     jMxtiil    llic   sc>\(mi11i   or   ci^lilli    day   after   operation   a   purg-ative   is 
given  and  soft  diet  is  begun. 

The  description  of  this  operation  was  reported  before  the  section  on 
Obstetrics,  Gynecology  and  Abdominal  Surgery,  at  the  meeting  of  the  Amer- 
ican Medical  Association,  in  June,  1919/°  The  only  changes  in  technic  since 
this  report  have  been  in  the  method  of  application  of  the  second  row  of  sutures 
and  in  placing  the  second  stay  suture  closer  to  the  first.  At  that  time  eleven 
cases  had  been  operated  upon  by  this  method.  There  were  two  deaths,  both 
of  them  from  hemorrhage,  and  in  both  instances  postmortem  examinations 
were  obtained.  One  death  occurred  on  the  twenty-first  day  after  operation  in 
a  patient  with  an  ulcer  of  the  posterior  wall  of  the  stomach  near  the  lesser  curv- 
ature. The  ulcer  was  removed  by  a  transgastric  incision  and  the  resulting  wound 
was  closed  with  mattress  sutures  of  stout  tanned  catgut.  Pyloroplast,y  was  then 
done.     The  patient  made  an  uneventful  recovery  until  the  eighteenth  dav  when 


^Ui    surface    vS 


jc^evi-OT 


wa\^ 


lessev    cu.- 


Tvatu,T<a- 


..-<<" 


;x^ 


.TVd-'^" 


^\^ 


,os^er>-°^' 


o-^^' 


Fig.  513. — A  drawing  of  the  stomach  removed  postmortem  from  a  patient  who  died  twenty-one  days 
after  pyloroplasty.  Death  was  due  to  hemorrhage  from  an  ulcer  involving  the  lesser  curvature.  Note  the 
large   vessel   protruding    in    the    ulcer    and    the    healing    of    the    pyloroplasty,    which    makes    a    wide    opening. 


he  had  a  severe  hemorrhage  from  the  stomach.  This  appeared  to  be  con- 
trolled by  gastric  lavage  with  hot  w^ater.  Twenty-four  hours  later  he  began 
vomiting  blood  and  in  spite  of  gastric  lavage  and  transfusion  of  blood  he 
died  on  the  tw^enty-first  day  after  the  operation.     Necropsy  was  held  a  few 


"Jour.  Am.  Med.  Assn.,  August  23,   1919,  p.  575,  et  seq. 


562  OrERATIVE    STTRGERY 

hours  after  death  and  the  stomach  was  obtained.  It  showed  that  the  pylorus 
had  healed  satisfactorily,  but  the  ulcer  had  extended  to  the  lesser  curvature 
and  involved  a  blood  vessel  of  considerable  size  that  was  protruding  from  the 
ulcer.     From  this  vessel  the  hemorrhage  undoubtedly  had  come  (Fig.  513). 

The  mattress  sutures  in  the  stomach  ulcer  evidently  were  tied  too  tightly 
and  caused  necrosis  of  the  mucosa  and  an  extension  of  the  ulcer  to  the  lesser 
curvature  where  there  were  large  vessels.  In  the  light  of  this  experience  I 
would  not  close  a  similar  ulcer  with  mattress  sutures,  but  with  layer  su- 
tures, uniting  first  the  peritoneal  and  muscular  coats.  The  sutures  can  be 
applied  after  placing  a  tractor  suture  at  each  end  of  the  wound  to  bring 
it  as  near  the  abdominal  wound  as  possible.  This  death  could  in  no  way 
be  attributed  to  the  pyloroplasty  which  had  healed  satisfactorily  and  left 
a  wide  open  pylorus  with  perfect  union,  as  shown  in  the  illustration. 

The  next  death  occurred  on  the  ninth  day  as  a  result  of  hemorrhage  which 
began  on  the  eighth  day  after  the  operation.  This  patient  had  a  marked  sten- 
osis of  the  pjdorus,  which  had  existed  for  a  number  of  years.  This  stenosis 
was  incised  posteriorly  at  the  operation  to  release  the  constricting  bands. 
There  was  moderately  free  hemorrhage  after  the  incision  into  the  bands  which 
was  readily  controlled  by  whipping  over  the  surface  with  tanned  catgut.  The 
catgut  was  absorbed  and  bleeding  began  on  the  eighth  day  from  this  incised 
surface.  The  post  mortem  examination  showed  very  small  vessels  had  been 
opened  where  the  bands  had  been  incised  and  the  catgut  was  digested  and 
absorbed.  The  pyloroplasty  incision  was  in  perfect  condition.  This  error  in 
technic  could  have  been  avoided  by  not  cutting  the  bands  so  deeply,  but  merely 
nicking  them  sufficiently,  so  that  the  incision  would  not  go  through  the  whole 
thickness  of  the  bands  and  reach  the  vessels  posteriorly.  Probably,  too, 
silk  sutures  in  this  area  would  be  preferable  to  catgut.  Profiting  by  these 
two  fatalities  there  has  been  no  hemorrhage  in  a  single  pyloroplasty  that  I 
have  done  since  this  group  of  cases  was  reported.  In  the  nine  patients  that 
recovered  from  operation  all  were  complaint  free  in  whom  the  ulcer  was  the 
chief  or  the  sole  pathologic  lesion  present. 

This  operation  as  shown  by  roentgenograms  restores^  the  stomach  to  a 
physiologic  normal,  protects  the  jejunum  from  being  a  dumping  ground  for 
the  acid  contents  of  the  stomach,  and  at  the  same  time  removes  the  ulcer 
which  is  the  cause  of  the  patient's  trouble. 

After  pyloroplasty  it  is  not  unusual  to  find  pain,  discomfort,  and  some- 
times hunger  pain,  if  there  was  an  adherent  gall  bladder  at  the  time  of  the 
pyloroplasty  and  the  gall  bladder  was  not  removed.  In  order  to  understand 
this,  we  must  remember  that  the  ulcer  of  the  duodenum  or  stomach  was,  in 
all  probability,  originally  caused,  as  shown  by  RosenoAV,  by  hematogenous  in- 
fection with  streptococci.  These  bacteria  have  to  some  extent  a  selective 
action,  but  usually  there  is  an  inflammation  of  the  gall  bladder  and  probably 
of  the  appendix  and  kidne^^s,  from  the  irritation  of  the  products  of  the  bac- 
teria when  the  ulcer  is  originally  formed.  Often  the  cholecystitis  is  rapidly 
overcome,  but  if  it  is  severe  enough  to  leave  adhesions,  that  gall  bladder  is 


THE   STOMACH  563 

ponnaiuMitly  daniaged.  Tf,  tlicn,  a  pyloroplasty  is  done  for  ulcer  of  the  duo- 
(Iciiuiu  (ir  sloinacli  avIumi  llie  o'all  ])]adder  is  adherent,  it  may  he  taken  as  a  defi- 
nite evidence  of  a  former  choU^eystitis.  If  the  adhesions  are  separated  and  the 
iiall  l)ladder  is  manipulated,  a  latent  infection  of  the  gall  gladder  is  often 
stirred  up,  adhesions  reform  with  double  severity  and  the  patient  will  have 
a  recurrence  of  symptoms.  If  a  gastroenterostomy  is  done,  these  symptoms 
will  be  relieved  for  a  few  months  or  longer,  until  jejunal  lesions  begin  to  give 
trouble. 

The  cause  of  this  discomfort  after  pyloroplasty  is  due  to  the  fact  that  ad- 
hesions from  the  gall  bladder  to  the  duodenum  or  pylorus,  in  a  stomach  that 
is  otherwise  normal,  permit  the  tugging  on  these  adhesions  with  each  peristal- 
tic wave  and  as  they  lead  directly  or  indirectly  to  the  tissues  along  the  poste- 
rior parietal  peritoneum  which  are  supplied  with  spinal  sensory  nerves,  an  un- 
usual amount  of  tugging  will  give  discomfort  and  pain.  Gastroenterostomy  re- 
lieves these  sj'mptoms  by  permitting  the  stomach  to  empty  more  easily  and 
in  this  way  reduces  the  amount  of  peristalsis  at  the  pyloric  end  of  the  stomach. 
It  relieves,  not  by  removing  the  pathology,  but  by  ameliorating  a  symptom. 
This  pain  can  be  best  prevented  by  bearing  in  mind  the  etiology  of  ulcer  of 
the  stomach  or  duodenum  and  removing  gall  bladders  that  are  adherent. 
When  doing  a  cholecystectomy  under  these  conditions,  following  the  tech- 
nic  of  Murat  AVillis,  the  stump  of  the  cystic  duct  should  not  be  drained. 
In  this  manner  the  adhesions  that  might  form  because  of  the  presence  of  the 
drainage  tube  are  obviated  and  the  stomach  and  duodenum  are  returned  as 
nearly  as  possible  to  their  physiologic  normal. 

There  exists,  hoAvever,  a  distinct  field  for  gastroenterostomy.  This  prob- 
ably does  not  constitute  more  than  twenty-five  per  cent  of  the  lesions  of  the 
stomach  and  duodenum,  but  there  are  three  types  of  cases  in  which  a  gastro- 
enterostomy is  a  better  operation  than  pyloroplasty. 

(1)  In  inoperable  cancer  of  the  pylorus  with  obstruction  the  necessity 
for  gastroenterostomy  is  obvious. 

(2)  In  dense  and  wide  stenosis  of  the  pylorus  and  upper  duodenum  when 
unaccompanied  by  hemorrhage  it  is  difficult  or  impossible  to  mobilize  the  duo- 
denum sufficiently  to  gain  access  to  it  and  pyloroplasty  is  much  more  diffi- 
cult than  in  simple  ulcer  or  in  a  slight  stenosis,  that  is  readily  accessible. 
Again,  this  type  of  case  gives  particularly  good  results  after  gastroenteros- 
tomy. 

(3)  In  subacute  perforation  or  in  large  ulcers  when  the  p^dorus  and  sur- 
rounding tissues  are  infiltrated  with  inflammatory  products,  the  tissues  are 
difficult  to  mobilize  and  do  not  hold  sutures  satisfactorily.  If  the  infiltration 
is  extensive  it  is  quite  probable  that  stenosis  will  result  and  such  cases  do  par- 
ticularly well  after  gastroenterostomy. 

In  acute  perforations,  however,  before  there  is  extensive  infiltration  of 
the  surrounding  tissues  and  when  the  duodenum  and  i^ylorus  are  accessible  and 
the  margins  of  the  ulcer  can  be  excised,  the  pyloroplasty  described  seems  to 
be  an  ideal  procedure,  for  it  confines  the  field  of  operation  to  the  region  of 


564  OPERATIVE    SURGERY 

the  perforation  and  avoids  the  possibility  of  spreading  the  infection  to  the 
lesser  peritoneal  cavity,  Avhich  may  oecnr  if  gastroenterostomy  is  done.  If 
there  is  marked  stenosis  and  bleeding  the  pyloroplasty  should  be  done  to 
secure  the  bleeding  vessels  or  break  the  scar  tissue  l)and  even  though  it  is  more 
difficult  than  gastroenterostomy.  The  pyloroplasty  may  be  short  and  on  ac- 
count of  the  tendency  of  dense  scar  tis.sue  to  contract,  a  gastroenterostomy  should 
also  be  done  at  the  same  time.  These  three  groups  will  comprise  a  considera- 
ble minority  of  cases  usually  seen  and  will  remove  the  type  of  cases  in  which  py- 
loroplasty is  quite  difficult.  In  the  average  case  with  a  single  ulcer  near  the  py- 
lorus a  pyloroplasty  is  easier  of  performance  than  gastroenterostomy,  but  with  a 
fixed  duodenum  and  pylorus  the  pyloro^Dlasty  becomes  increasingly  difficult.  It 
is  in  this  type  of  case,  however,  that  gastroenterostomy  gives  the  best  results. 

It  has  often  been  remarked  by  operators  who  have  had  much  experience 
with  pyloric  stenosis  that  gastroenterostomy  gives  its  best  results  here.  Thus 
Balfour,^^  in  speaking  of  the  results  of  gastroenterostomy  in  obstruction  at 
the  pyloric  outlet,  says:  "Particularly  when  mechanical  obstruction  has  oc- 
curred from  contraction  of  the  ulcer  or  by  reason  of  its  actual  size,  operation  is 
followed  by  eminently  satisfactory  results."  This  experience  seems  to  be 
universal. 

AVhy  should  gastroenterostomy  give  such  satisfactory  results  in  stenosis 
of  the  pylorus  w^hen  the  results  wdthout  stenosis  leave  much  to  be  desired  f  Sten- 
osis of  the  iDylorus,  even  when  incomplete,  probably  becomes  complete  after  gas- 
troenterostomy which  removes  the  necessity  for  strong  peristaltic  action  to  empty 
the  stomach  and  causes  a  contraction  of  the  whole  stomach.  It  is  impossible  for 
the  same  intragastric  pressure  to  be  brought  to  bear  upon  the  pyloric  end  of  the 
stomach  when  a  gastroenterostomy  is  done  because  the  opening  of  the  gastroenter- 
ostomy makes  great  intragastric  pressure  an  impossibility.  When  gastroenter- 
ostomy is  done  for  stenosis  at  the  pylorus  the  gastric  contents  empty  entirely 
through  the  gatroenterostomy.  The  duodenal  contents  with  strongly  alka- 
line reaction,  W'hich  is  unreduced  by  any  gastric  juice  coming  through  the 
pylorus,  are  delivered  at  the  site  of  the  gastroenterostomy  with  maximum 
alkalinity.  The  acidity  of  the  gastric  juice  is,  therefore,  quickly  and  readily 
neutralized,  so  the  mucosa  of  the  jejunum  is  protected  from  the  action  of  a 
strongly  acid  gastric  juice.  When,  how^ever,  the  pylorus  is  open  and  gastro- 
enterostomy is  done,  part  of  the  gastric  contents  goes  through  the  pylorus 
and  part  through  the  gastroenterostomy..  That  part  going  through  the  pylorus 
greatly  reduces  the  alkalinity  of  the  duodenal  contents,  so  when  the  duodenal 
secretion  reaches  the  gastroenterostomy  opening  its  alkalinity  is  low  and  the 
acidity  of  the  gastric  contents  overcomes  it  and  acts  directly  upon  the  jejunum, 
which  consequently  registers  some  reaction  to  the  presence  of  an  acid  medium. 

It  seems,  then,  that  the  excellent  results  following  gastroenterostomy 
when  there  is  stenosis  of  the  pylorus  occur  because  the  high  alkalinity  of  the 
duodenal  contents  protects  the  jejunum  from  the  presence  of  an  acid  medium 


^Collected  Papers  of  the  Mayo   Clinic,    1916,  viii,  p.   171. 


THE    STOMACH  565 

and  so  the  jejunum  has  no  occasion  to  react  against  an  unphysiologic  medium 
b}^  becoming  congested  or  by  ulcer  formation.  Artificial  closure  of  the  pylorus 
has  been  disappointing  in  the  attempt  to  simulate  pyloric  stenosis  because 
practically  every  method  of  pyloric  closure  except  excision  results  in  the 
pylorus  eventually  opening  again.  While  the  pylorus  is  closed  the  conditions 
are  the  same  as  after  an  organic  stenosis,  but  with  the  reopening  of  the 
pylorus,  such  as  occurs  after  infolding  or  ligation,  the  gastric  juice  again 
escapes  through  the  pylorus  and  reduces  the  alkalinity  of  the  duodenal  con- 
tents, with  the  resulting  lack  of  protection  of  the  jejunum.  This,  of  course, 
quickly  causes  the  same  reaction  on  the  part  of  the  jejunum  as  would  have 
occurred  if  the  pylorus  had  not  been  closed. 

Gastroenterostomy  is  best  performed  by  the   posterior  no  loop   method, 
which  has  been  developed  by  the  Mayos,  Moynihan  and  others.    The  operation 


Fig.    514. — Diagram   of   the   incisions,   and    direction   of   the    opening   in   posterior   gastroenterostomy. 

(W.    J.    Mayo). 

as  performed  at  the  Mayo  Clinic  is  a  most  satisfactory  technic  (Fig.  514). 
The  stomach  is  exposed  by  an  incision  a  little  to  the  right  of  the  midline  and 
the  stomach  and  duodenum  are  examined.  The  transverse  colon  is  drawn  out 
of  the  wound  and  pulled  upAvard  to  the  right  to  make  the  mesocolon  taut. 
The  jejunum  is  recognized  as  it  comes  out  from  the  mesocolon  and  is  picked 
up  about  three  inches  from  its  origin.  Sometimes  there  is  a  fold  of  perito- 
neum passing  from  the  mesocolon  to  the  jejunum  which  should  be  divided  if 
it  extends  far  down  on  the  jejunum,  as  this  may  prevent  the  jejunum  being 
caught  as  high  up  as  it  should  be.  About  where  this  fold  joins  the  mesocolon 
the  mesocolon  is  opened  in  a  bloodless  area  and  the  posterior  wall  of 
the  stomach  is  exposed.  An  opening  is  made  sufficiently  large  to  give  exit 
to  a  considerable  portion  of  the  posterior  gastric  wall  without  constric- 
tion. Following  the  suggestion  of  McArthur,  the  posterior  portion  of 
the  rent  in  the  mesocolon  is  now  sutured  to  the  posterior  part  of  the 
stomach  wall  by  a  few  interrupted  sutures  of  catgut.     This  procedure  is  best 


566 


OPERATIVE    SURGERY 


done  at  this  stage  of  the  operation  as  the  suturing  can  be  more  accurately 
api)lied  than  after  the  jejunum  and  stomach  are  united   (Fig.  515). 

A  gastroenterostomy  clamp,  preferably  the  Roosevelt  clamp,  is  applied  to  the 
stomach  in  such  a  way  that  the  bite  on  the  stomach  wall  will  be  from  the  right  side 
obliquely  toward  the  left  and  the  tip  of  the  forceps  includes  a  portion  of  the 
stomach  at  the  greater  curvature.  The  jejunum  is  caught  and  clamped  in  its 
long  axis  from  two  to  four  inches  from  its  origin,  and  the  clamped  portion  is 
applied  to  the  stomach  so  that  the  upper  part  of  the  jejunum  is  at  the  heel  of 
the  stomach  clamp  and  toward  the  right.  The  surrounding  tissues  are  pro- 
tected by  moist  gauze  and  the  jejunum  is  united  to  the  stomach  for  a  distance 
of  about  two  and  one-half  inches  by  a  row  of  continuous  sutures,  preferably 
of  tanned  or  chromic  catgut.     The  short  end  of  the  suture  is  clamped  with 


Fig.  515. — Posterior  gastroenterostomy.  The  posterior  part  of  the  stomach  is  sutured  to  the  rent 
in  the  mesocolon.  The  portion  of  jejunum  to  be  opened  is  shown,  but  the  clamp  should  be  reversed,  and 
its  tip  point  to  the  left. 


forceps.  After  the  posterior  row  has  been  completed  the  needle  and  thread 
are  clamped  with  mosquito  forceps  and  folded  in  a  towel.  The  sutures  may 
be  applied  as  a  simple  continuous  stitch  or  as  a  right-angle  suture,  preferably 
the  latter.  The  stomach  and  duodenum  are  incised  about  a  third  of  an 
inch  from  this  row  of  sutures.  The  incision  had  best  be  made  carefully 
and  any  vessels  that  can  be  recognized  should  be  doubly  clamped  and  divided 
before  opening  the  mucosa  (Fig.  516).  These  vessels  are  then  tied  with  cat- 
gut. This  step  consumes  but  little  extra  time  and  makes  a  much  greater  assur- 
ance that  there  will  be  no  after  bleeding.  The  mucosa  of  the  stomach  is 
divided  throughout  the  length  of  the  incision  and  then  the  mucosa  of  the 


THE    STOMACH 


567 


cluocleiiiim.  The  contents  of  the  clamped  stomach  and  duodenum  are  removed 
hy  sponges.  A  second  row  of  sutures  is  begun.  This  is  also  tanned  or  chromic 
catgut  but  is  larger  than  the  first  row,  the  first  being  0  or  00  and  the  second 
No.  1  or  No.  2.  Either  a  curved  or  a  straight  needle  may  be  used.  This  suture 
is  begun  at  the  end  of  the  incision  where  the  needle  and  thread  of  the  first  line  of 
sutures  has  been  left.  The  short  end  is  clamped  and  the  suture  is  continued  as 
a  buttonhole  or  lock  stitch,  each  stitch  being  held  snugly  (Fig.  517).  When 
it  reaches  the  other  end  it  is  continued  on  the  anterior  margins  of  the  gastric 
and  the  jejunal  wound  as  a  continuous  mattress  stitch  penetrating  all  coats.  A 
very  small  margin  of  the  stomach  or  jejunum  is  caught  with  this  suture  so  as 
not  to  fold  in  any  more  tissue  than  is  necessary.  If  the  stomach  wall  is  quite 
thick  this  suture  can  often  be  inserted  more  accurately  by  carrying  the  needle 
from  the  peritoneal  surface  through  the  mucosa  and  then  back  from  the  mu- 


Fig.  516. — The  stomach  and  jejunum  have  been  clamped  and  a  posterior  row  of  sutures  is  placed. 
The  stomach  and  jejunum  are  incised  down  to  but  not  through  the  mucosa.  The  next  step  is  the  clamp- 
ing and   tying  of  dilated  vessels  before  the  mucosa  is   opened. 


cosa  to  the  peritoneal  surface.  This,  of  course,  may  be  accomplished  by  a 
single  thrust  of  the  needle,  but  in  a  thick  stomach  wall  it  causes  a  larger 
amount  of  the  peritoneal  and  muscular  coat  than  the  mucosa  to  be  caught  in 
the  bite  of  the  needle,  whereas  if  the  needle  is  thrust  in  perpendicularly  and 
returned  in  the  same  way  an  equal  amount  of  all  the  layers  of  the  stomach 
wall  are  grasped  and  there  is  less  likelihood  of  bleeding  points  in  the  mucosa 
escaping.  With  a  curved  needle  a  single  thrust  is  more  likely  to  catch  more  of 
the  mucosa  than  with  a  straight  needle.  Just  before  ending  this  row  of 
sutures  the  clamps  are  relaxed  to  see  if  there  is  any  bleeding  along  the  pos- 
terior or  the  anterior  margins  of  the  wound.     If  there  is,  additional  sutures 


568 


OPERATIVE    SURGERY 


should  be  applied  at  the  bleeding  point.  If  not,  this  second  row  of  sutures 
is  continued  to  its  point  of  beginning  and  the  thread  tied  to  the  short  end  that  was 
clamped. 

The  line  of  suture  is  carefully  sponged  with  moist  gauze  and  the  needle 
and  thread  left  after  placing  the  first  posterior  row  of  sutures  is  taken  up 
and  the  first  row  is  continued,  using  preferably  a  right-angle  continuous 
stitch  and  going  about  one-fourth  to  one-third  of  an  inch  from  the  inner  row 
of  sutures.  When  it  reaches  its  point  of  beginning  this  suture  is  tied  to  the 
original  end  that  was  left  long.  An  interrupted  mattress  suture  is  taken  at 
each  end  of  the  gastroenterostomy  to  lessen  the  strain  on  the  sutures  at 
these  points.     The  anterior  portion  of  the  rent  in  the  mesocolon  is  sutured 


Fig.    517. — The    second    row    of    sutures    has    been    placed    in    the    posterior    margins    of    the    wound    and    is 

carried   forward   to   the  anterior   margins. 


to  the  stomach  by  interrupted  sutures  of  tanned  or  chromic  catgut  placed 
about  an  inch  from  the  gastroenterostomy  opening.  It  was  formerly  the  cus- 
tom to  suture  the  rent  over  the  last  row  of  sutures  used  for  gastroenterostomy 
but  W.  J.  Mayo  found  that  occasionally  this  opening  contracted  and  produced 
constriction  of  the  gastroenterostomy  stoma.  By  suturing  the  rent  about  an  inch 
higher  on  the  stomach  the  constriction  is  avoided.  As  one  of  the  first  steps 
in  the  operation  consisted  in  suturing  the  posterior  margin  of  the  mesocolon 
to  the  stomach  the  anterior  or  lateral  aspects  are  all  that  require  suturing. 
This,  however,  is  an  important  step  in  the  operation.  If  it  is  not  done  there 
may  be  a  hernia  of  the  small  intestine  into  the  lesser  peritoneal  cavity. 

The   location   of   the    gastroenterostomy    opening    as    described   above    is 
almost  opposite  the  esophageal  opening.    A  vicious  circle  which  was  formerly 


THE    STOMACH 


569 


common  after  posterior  gastroenterostomy  with  a  loop,  is  rarely  seen  when  the 
no  loop  method  is  employed.  Occasionally,  however,  there  may  be  an  indica- 
tion for  such  an  operation  that  would  make  a  vicious  circle  impossible.  This 
is  done  according  to  the  method  of  Roux  and  is  often  called  the  operation 
**en  Y."  The  structures  are  exposed  as  in  posterior  gastroenterostomy  but 
the  jejunum  is  caught   about   six   inches   below  its   origin,   doubly  clamped 


Fig.  518. — The  gastroenterostomy   of  Roux  to  prevent  vicious  circle.     This  operation   seems  peculiarly  liable 

to  be  followed  by  jejunal  ulcer.   . 

and  divided.  The  lower  end  is  sutured  to  the  posterior  wall  of  the  stomach 
which  is  exposed  as  in  the  operation  of  gastroenterostomy  just  described.  The 
upper  end  is  sutured  by  the  end-to-side  method  to  the  jejunum  about  five  inches 
below  the  gastroenterostomy  opening  (Fig.  518). 

Excision  of  an  ulcer  should  be  done  wherever  possible.  This  procedure 
not  only  removes  a  septic  focus,  but  wdien  the  ulcer  is  in  the  stomach 
it  lessens  the  possibility  of  cancer  which  occurs  in  a  certain  percentage  of 
ulcers  of  the  stomach.  When  the  ulcer  is  on  the  anterior  surface  of  the  stom- 
ach and  near  the  pylorus,  excision  is  readily  done.  This  may  be  accomplished 
through  the  pyloroplasty  incision  made  in  such  a  way  that  it  will  be  near  the 
edge  of  the  ulcer,  which  is  excised  from  the  mucous  surface.  It  is  best  to 
cauterize  the  ulcer  with  the  cautery  to  sterilize  its  surface  before  removing  it. 


570  OPERATIVE    SURGERY 

When  the  ulcer  is  so  located  that  it  cannot  be  readily  brought  into  the  region 
of  the  pyloroplasty  incision,  it  is  removed  through  a  separate  incision.  A 
frequent  site  of  gastric  ulcer  is  along  the  lesser  curvature.  The  blood  vessels 
in  the  mesentery  are  ligated  along  the  edge  of  the  ulcer  and  the  gastro- 
hepatic  omentum  is  divided.  The  portion  of  the  stomach  containing  the  ulcer 
is  mobilized  as  much  as  possible  and  surrounded  by  moist  gauze.  With  a 
sharp  knife  an  incision  is  made  along  the  margin  of  the  ulcer  cutting  down  to, 
but  not  through,  the  mucosa.  Bleeding  points  are  clamped  and  tied  by  trans- 
fixing them  with  catgut  in  a  needle.  It  will  be  found  that  the  mucosa  is  more 
easily  mobilized  than  the  other  layers  of  the  stomach  wall.  After  circumscrib- 
ing the  ulcer  in  this  manner  the  mucosa  is  opened  with  the  electric  cautery  at  its 
anterior  portion  and  the  ulcer  is  inspected.  The  rest  of  the  mucosa  is  then  di- 
vided with  the  cautery  in  such  a  way  that  there  is  a  small  margin  of  healthy 
mucosa  excised  with  the  ulcer.  The  mucosa  is  sutured  as  a  separate  layer  with 
tanned  catgut,  using  a  continuous  lock  stitch.  If  the  sutures  can  be  placed 
in  a  straight  line,  without  too  much  tension,  it  should  be  done.  The  incision 
in  the  stomach  may  often  be  made  in  an  oblique-  or  diamond-shaped  manner 
which  will  render  such  a  closure  not  difficult.  The  important  point  is  to  unite 
the  edges  of  the  mucosa  without  tension.  A  second  row  of  sutures  of  No.  1 
tanned  or  chromic  catgut  in  a  curved  round  needle  is  placed  taking  the  mus- 
cular coat  and  edges  of  the  peritoneum.  This  may  be  placed  as  a  right-angle 
stitch,  taking  an  occasional  back  stitch  in  order  to  anchor  the  line  of  sutures 
at  about  every  fourth  insertion  of  the  needle,  or  if  there  is  tension  the  second 
roAV  is  inserted,  as  the  second  row  in  pyloroplasty.  A  third  row  of  finer 
tanned  or  chromic  catgut  is  inserted  as  a  right-angle  stitch.  The  stumps  of 
the  ligated  gastrohepatic  omentum  are  brought  together  over  the  wound  and 
fastened  with  interrupted  catgut  sutures.  Suturing  the  ulcer  in  this  manner 
will  take  up  a  minimum  amount  of  the  wall  of  the  stomach  and  will  produce 
but  little  tension.  If  through-and-through  sutures  are  taken  as  the  first  layer 
a  large  mass  of  inverted  tissue  is  turned  in  which  not  only  encroaches  greatly 
on  the  wall  of  the  stomach,  but  is  likely  to  cause  tension  on  the  sutures  and 
make  an  unnecessary  lump  of  tissue. 

Ulcers  on  the  posterior  gastric  wall  are  often  difficult  to  approach.  If 
adherent  to  the  pancreas  their  excision  may  be  complicated.  If  the  ulcer  is 
near  the  lesser  curvature  it  can  be  reached  by  ligating  and  dividing  the  gas- 
trohepatic omentum  immediately  above  it  and  making  a  vertical  incision 
over  the  upper  portion  of  the  anterior  stomach  wall,  which  will  expose  the 
ulcer,  and  then  continuing  the  incision  posteriorly  as  an  elliptical  or  diamond- 
shaped  incision  that  will  include  the  ulcer.  The  wound  is  then  sutured  by 
placing  tractor  sutures  in  the  posterior  angle  and  drawing  the  wound  forward. 
Suturing  is  begun  in  the  mucosa  at  the  posterior  angle  and  carried  forward  to 
the  anterior  end  of  the  incision  as  a  continuous  lock  stitch  of  tanned  or  chromic 
catgut.  The  second  row  is  of  tanned  or  chromic  catgut  to  approximate  the 
margins  of  the  wound,  and  the  third  is  of  finer  tanned  or  chromic  catgut  placed 


THE    STOMACH 


571 


as  a  right-angle  stitcli.    The  gastrohepatic  omentum  is  hronght  togetlier  as  in 
excision  of  an  ulcer  on  the  lesser  curvature. 

When  the  ulcer  is  near  the  middle  of  the  posterior  wall  it  can  1)c  reached 
by  a  transgastric  incision.  This  may  be  vertical  or  longitudinal  in  the  ante- 
rior wall  of  the  stomach.  If  a  longitudinal  incision  is  made  it  should  be  about 
midAvay  between  the  lesser  and  greater  curvatures  so  as  to  avoid  the  larger 
blood  vessels  and  to  injure  as  little  as  possible  tlie  nerve  supply.  If  the 
ulcer  is  nonadherent  it  may  be  pushed  into  the  wound  by  the  hand,  which 
invaginates  the  transverse  mesocolon  into  the  lesser  peritoneal   cavity  and 


mi 

*"\; 

'  V'rf:Si 

Ih 

^fe"fe 

i 

I 

mm- 

/ 

/ 

Fig.    519. — Incision    through    the    gastrohepatic    and    gastrocolic    omentum    to    expose    ulcer    in    posterior    wall 

of   the    stomach. 


shoves  the  posterior  wall  of  the  stomach  into  the  wound.  If  the  ulcer 
is  adherent,  the  lesser  peritoneal  cavity  is  opened  either  through  the  gas- 
trohepatic omentum  or  the  gastrocolic  omentum  and  the  region  of  the  ulcer 
is  carefully  packed  around  with  moist  gauze  to  prevent  soiling  of  the  sur- 
rounding tissue  (Fig.  519).  The  adhesions  may  then  be  carefully  separated 
with  the  finger  in  the  lesser  peritoneal  cavity  or  if  they  are  dense  they  may 
be  separated  after  incising  the  margin  of  the  ulcer  from  within  the  stomach 
through  an  incision  in  the  anterior  gastric  Avail.  Such  an  incision  should  be 
carried  along  a  margin  of  the  ulcer  for  a  short  distance  and  carefully  enlarged 
and  deepened  until  the  stomach  has  been  penetrated.     Then  with  the  fin- 


572  OPERATIVE    SURGERY 

ger  the  margins  of  the  ulcer  may  be  separated.  If  the  pancreas  is  involved 
a  small  portion  of  the  pancreas  may  be  cut  away  and  the  bleeding  surface 
whipped  over  with  tanned  or  chromic  catgut  which  is  tied  just  tightly  enough 
to  control  the  bleeding.  Here  it  would  be  wise  to  carry  a  cigarette  drain  down 
to  the  injured  pancreas  and  bring  the  drain  out  through  the  rent  in  the  gas- 
trocolic omentum.  After  mobilizing  the  ulcer  it  is  brought  up  into  the  wound, 
its  surface  is  cauterized  with  an  electric  cautery,  and  the  ulcer  is  ex- 
cised. Bleeding  points  are  secured  by  transfixing  them  with  catgut  in  a 
needle.  The  peritoneal  and  muscular  coats  are  sewed  with  interrupted  mat- 
tress sutures  of  tanned  or  chromic  catgut.  The  ends  are  securely  tied  and 
cut  short  and  a  second  layer  of  tanned  or  chromic  catgut  right-angle  suture 
is  applied  to  include  the  muscular  wall  of  the  stomach  and  some  of  the  sub- 
mucosa.  The  third  row  is  a  continuous  lock  stitch  of  fine  tanned  or  chromic 
catgut  in  the  mucosa.  This  method  is  much  safer  than  endeavoring  to  place 
interrupted  mattress  sutures  of  stout  catgut  or  silk  through  the  whole  gastric 
wall  for  these  sutures  must  be  tied  tightly  to  secure  approximation  and  the 
blood  supply  to  the  tissues  within  their  grasp  is  either  diminished  or  cut 
off  entirely.  There  will,  consequently,  be  necrosis,  and  though  the  perito- 
neal surfaces  of  the  stomach  may  unite,  the  mass  of  tissue  within  the 
grasp  of  the  sutures  in  the  interior  of  the  stomach,  including  a  considerable 
amount  of  mucosa,  will  probabl}-  die.  This  gives  rise  to  a  new  ulcer  that  may 
be  more  extensive  than  the  original  one. 

Not  infrequently  on  account  of  adhesions,  the  extent  of  the  ulcer,  or  its 
inaccessible  location  it  is  impossible  or  exceedingly  difficult  to  excise  the 
ulcer.  Here  the  method  of  cauterizing  the  ulcer  as  devised  by  D.  C.  Balfour, 
should  be  employed.  According  to  the  technic  of  Balfour,  the  gastrohepatic 
omentum  in  the  region  of  the  ulcer  is  dissected  free  from  the  lesser  curvature. 
An  ulcer  that  requires  cauterization  and  cannot  be  safely  excised  is  always 
along  the  lesser  curvature.  After  exposing  the  region  of  the  ulcer  a  flap 
of  tissue  over  it,  including  the  peritoneum  and  muscular  coat,  is  raised, 
the  crater  of  the  ulcer  is  demonstrated  and  is  perforated  by  a  Paquelin  or 
an  electric  cautery  at  a  dull  red  heat.  The  cauterization  is  continued  until  the 
whole  of  the  surface  of  the  ulcer  has  been  destroyed.  The  margins  of  the 
cauterized  area  are  then  brought  together  by  interrupted  sutures  of  chromic 
catgut  and  over  this  are  placed  mattress  sutures  of  silk.  Lastly  a  flap  of 
gastrohepatic  omentum,  which  was  originally  loosened  and  preserved,  is  su- 
tured over  the  wound. 

After  excision  of  any  ulcer  a  pyloroplasty  should  be  done  to  overcome 
the  spasm  at  the  pylorus.  The  pyloroplasty  which  has  been  described  will 
suit  admirably  and  when  done  to  relieve  the  spasm  at  the  pylorus  that  follows 
the  excision  of  an  ulcer  in  the  body  or  cardiac  portion  of  the  stomach,  the 
total  length  of  the  incision  need  be  only  about  two  or  two  and  one-half  inches, 
taking  care,  however,  that  no  more  than  one-third  of  the  total  length  is  in  the 
duodenum  and  the  rest  of  the  incision  is  in  tlie  stomach.  Any  operation  upon 
the  stomach  interferes  with  its  peristalsis  and  emptying  power.     Just  as  an 


THE    STOMACH.  573 

operation  upon  the  urinary  bladder  interferes  with  its  power  to  empty  and 
should  be  followed  by  the  introduction  of  an  indwelling  catheter,  so  an  opera- 
tion upon  the  stomach  must  provide  easy  exit  for  its  contents  by  overcoming 
the  resistance  at  the  pylorus.  The  pyloroplasty  does  this  without  instituting 
the  unphysiologic  conditions  already  described  which  necessarily  follow  a 
gastroenterostomy,  and  by  the  time  the  wound  in  the  stomach  has  thoroughly 
healed  the  pyloric  end  of  the  stomach  functions  in  a  practically  normal  man- 
ner. There  should  be  no  hesitation  about  the  use  of  a  stomach  tube  after  such 
operations  upon  the  stomach.  If  the  stomach  tube  is  used  with  reasonable  care 
and  if  the  stomach  is  washed  out  with  a  small  amount  of  soda  solution  under 
low  pressure,  this  will  be  much  less  trying  upon  the  healing  of  the  wound  than 
the  retention  of  gastric  contents  or  the  tension  upon  the  suture  line  from  a 
stomach  dilated  with  liquid  or  gas. 

In  old  ulcers  with  pronounced  hourglass  constriction  or  where  a  consid- 
erable portion  of  the  gastric  wall  is  involved  a  transverse  or  sleeve  resection 
of  the  stomach  often  produces  better  results  than  an  extended  V-shaped 
resection.  The  sleeve  or  transverse  resection  is  performed  after  ligating  the 
vessels  in  the  gastrohepatic  omentum  along  the  margins  of  the  proposed  incis- 
ions for  resection.  The  gastrohepatic  omentum  is  divided  and  the  lesser  peri- 
toneal cavit}^  is  packed  with  moist  gauze.  With  the  hand  in  the  lesser  peri- 
toneal cavity  the  gastrocolic  omentum  is  raised  in  such  a  manner  as  to  avoid 
injury  to  the  transverse  mesocolon.  The  gastroepiploic  arteries  are  clamped, 
divided  and  tied  at  about  the  proposed  lines  for  the  excision,  just  as  the  gastric 
and  pyloric  have  been  tied  in  the  gastrohepatic  omentum.  This  section  of  the 
stomach  is  thus  mobilized  and  packed  off  from  the  surrounding  tissues  with 
moist  gauze.  A  long  rubber-covered  stomach  clamp  is  placed  as  far  to  the  car- 
diac side  as  possible  in  order  to  occlude  the  stomach  and  to  leave  a  margin  of 
about  one  and  one-half  inches  of  stomach  after  the  excision  has  been  done. 
A  similar  clamp  is  placed  on  the  pyloric  portion  of  the  stomach.  If  there  is  no 
reasonable  suspicion  of  malignancy  the  diseased  segment  of  the  stomach  is 
now  cut  away  with  knife  or  scissors.  If,  however,  malignancy  is  suspected 
the  incision  in  the  stomach  had  best  be  made  Avith  an  electric  cautery.  The 
posterior  peritoneal  surfaces  of  the  stomach  wall  are  united  by  a  series  of  in- 
terrupted mattress  sutures  of  silk  or  linen,  which  include  the  peritoneal  and 
muscular  coats.  It  is  best  to  insert  all  of  these  sutures  before  tying  any.  After 
tying  them  the  ends  of  the  sutures  are  cut  short  except  the  ends  at  the  greater 
curvature  and  at  the  lesser  curvature.  These  are  left  long  and  act  as  tractor 
sutures. 

The  pressure  on  the  stomach  clamps  should  be  slightly  relaxed  to  dem- 
onstrate bleeding  points.  If  there  is  spurting  at  any  point  the  vessels 
are  controlled  by  transfixing  the  tissues  around  them  with  catgut  in  a 
needle.  The  clamps  are  then  tightened  and  a  continuous  suture  of  No.  1 
or  No.  2  tanned  or  chromic  catgut  is  begun  at  the  upper  margin  of  the 
wound  and  penetrates  all  coats  of  the  stomach,  being  inserted  from  the 
surface   of  the  mucosa.     Care  is  taken  to  begin  the   sutures  a  little   ante- 


574  OPERATIVE   STTRGERY 

riorly  to  the  upper  extremity  of  the  incision.  After  tying  the  knot  three 
times  the  short  end  is  chimped  -with  forceps.  The  suturing  is  continued 
as  a  lock  stitch  snugly  applied  over  the  posterior  margin  of  the  wound. 
When  it  reaches  the  greater  curvature  it  is  converted  into  a  right-angle  con- 
tinuous suture  penetrating  all  coats,  but  taking  a  bite  of  peritoneum  close 
to  the  Avound  and  locking  every  fourth  insertion  of  the  needle  by  a  back 
stitch,  by  taking  a  bite  in  the  tissue  a  little  behind  the  stitch  that  has 
just  been  inserted.  Just  before  reaching  the  point  of  beginning  of  the  su- 
ture, the  clamps  are  relaxed  and  bleeding  points  are  again  looked  for 
and  controlled  by  interrupted  sutures  of  catgut.  The  suture  is  continued 
and  tied  to  the  original  end  which  was  clamped  with  forceps  when  the 
first  knot  was  tied.  A  second  layer  of  either  continuous  right-angle  su- 
tures of  fine  tanned  or  chromic  catgut  or  interrupted  mattress  sutures  of 
silk  or  linen  is  applied.  At  the  upper  angle  an  extra  suture  is  placed  to 
relieve  tension  at  this  point.  The  stumps  of  the  gastrohepatic  omentum,  where 
the  blood  vessels  have  been  tied,  are  brought  over  the  wound  and  fastened 
with  interrupted  sutures.  A  similar  procedure  is  done  at  the  lower  angle 
of  the  wound,  fastening  the  gastrocolic  omentum  over  the  wound  in  this 
region.  A  pyloroplasty  should  be  done  in  order  to  relieve  the  spasm  at  the 
pylorus.     This  requires  only  a  short  incision  in  the  stomach  and  duodenum. 

The  technic  of  excision  of  the  stomach  for  cancer  has  been  greatly  im- 
proved by  the  method  of  Polya  which  is  now  ciuite  generally  adopted.  For- 
merly gastrectomy  for  cancer,  which  usually  involves  the  pyloric  end  of  the 
stomach,  was  done  according  to  the  second  method  of  Billroth.  This  con- 
sists in  excising  the  pyloric  end,  closing  the  duodenum  and  the  stomach  and 
doing  a  gastroenterostomy.  It  was  not  only  a  tedious  operation,  but  the 
technic  of  gastroenterostomy  performed  on  the  small  stump  of  the  cardiac 
end  of  the  stomach  is  quite  difficult  and  involves  tissue  whose  nutrition  is 
impaired  by  the  ligation  of  some  of  the  vessels  that  supply  the  stomach, 
which,  of  course,  is  necessary  in  the  performance  of  the  excision. 

The  principle  of  the  Polya  operation  consists  in  applying  the  jejunum 
directly  to  the  wound  in  the  stomach.  The  advantages  of  .this  procedure  are 
obvious.  It  enables  more  of  the  stomach  to  be  removed  because  the  wound 
by  the  old  technic  was  infolded  and  carefully  sutured,  which  takes  at  least 
an  inch  more  of  the  stomach  than  when  it  is  sutured  directly  to  the  jejunum. 
Then,  too,  the  nutrition  of  the  stump  of  the  stomach  is  augmented  by  applying 
to  it  a  loop  of  jejunum  whose  blood  supply  has  been  unimpaired.  The  time  of 
the  operation  is  shortened  by  removing  the  necessity  of  a  gastroenterostomy. 

According  to  the  original  Polya  method  the  jejunum  was  brought  up 
through  a  rent  in  the  mesocolon  as  in  gastroenterostomy.  D.  C.  Balfour  has 
added  a  great  improvement  in  this  technic  by  bringing  the  loop  of  jejunum 
over  the  transverse  colon  as  when  an  anterior  gastroenterostomy  is  performed. 
The  technic  of  Balfour's  modification  of  the  Polya  operation  is  as  follows:  The 
vessels  that  supply  the  pyloric  portion  of  the  stomach  are  ligated  at  a  short 
distance  from  the  proposed  line  of  excision,  the  gastric  artery  being  first 


THE    STOMACH 


575 


doubly  elampod,  divided  and  tied  in  the  "astroliepatie  omentum  and  then  the 
pyloric  artery  is  similarly  treated.  As  much  of  the  gastrohepatic  omentum  as 
possible  is  removed,  including  all  enlarged  glands  and  going  as  high  up  on 
the  lesser  curvature  as  is  practicable.  Lymphatic  metastases  extend  along  the 
lesser  curvature  more  rapidly  than  at  other  points.  After  the  vessels  at  the 
lesser  curvature  have  been  secured  and  the  gastrohepatic  omentum  has  been 
divided,  the  lesser  peritoneal  cavity  is  entered  from  above  by  inserting  the 
hand  and  lifting  the  stomach  forward.  The  gastroepiploic  artery  along  the 
greater  curvature  of  the  stomach  is  doubly  clamped,  divided,  and  tied.     The 


Fig.  520. — Gastrectomy.  The  stomach  has  been  mobilized  and  isolated  except  at  its  pyloric  and  cardiac 
ends.  The  crushing  clamps  have  been  placed  and  the  lines  of  incision  are  indicated.  The  pylorus  is 
first  divided. 


gastrocolic  omentum  is  divided  near  the  colon,  the  vessels  being  doubly 
clamped  before  they  are  divided.  Care  is  taken  in  this  region  to  avoid  in- 
jury to  the  blood  vessels  of  the  transverse  mesocolon.  If  the  colic  artery 
is  injured  it  may  be  necessary  to  resect  the  transverse  colon,  which  would 
be  a  grave  complication  in  these  cases.  By  working  from  the  cardiac  end 
toward  the  pylorus  and  pushing  the  transverse  colon  out  of  the  way  such 
an  accident  should  be  avoided.  The  right  gastroepiploic  artery  is  doubly 
clamped  and  divided  near  the  beginning  of  the  duodenum.  Here  the  meso- 
colic  vessels  are  very  near.  All  vessels  that  have  been  clamped  are  now  tied 
so  as  to  have  as  fcAV  forceps  in  the  field  as  possible. 


576 


OPERATIVE    SURGERY 


The  large  Payr  crushing  clamp  is  applied  to  the  body  of  the  stom- 
ach at  the  line  of  the  proposed  resection.  Two  smaller  Payr  clamps  are 
placed  on  the  duodenum  near  the  pylorus.  The  segment  to  be  removed 
may  be  clamped  with  ordinary  pedicle  or  stomach  forceps  instead  of  the  Payr 
instrument   Avhich   should   always   be   used   on   the    remaining    stumps.    (Fig, 


Fig.   521. — The   duodenal   stump  is   sutured   over   with   a   right-angle   continuous   suture   which   is   drawn   tight 

after  the  clamp  is  removed. 


Fig.   522. — Pursestring  sutures   are   added   still   further   to   invaginate   the    duodenal   stump. 


520).  The  stomach  is  divided  with  the  electric  cautery  at  the  pyloric  end. 
The  duodenum  is  closed  by  a  pursestring  suture  of  tanned  or  chromic  catgut. 
This  end  is  further  inverted  by  a  pursestring  suture  of  silk  or  linen  applied 
about  half  an  inch  from  the  original  suture  and  still  another  pursestring 
suture  is  placed  to  bury  this  second  suture  (Figs.  521  and  522).  A  few  inter- 
rupted sutures  of  silk  or  linen  are  placed  to  draw  the  capsule  of  the  pancreas 


THE    STOMACH 


577 


and  the  omentum  in  the  neighborhood  over  the  end  of  the  duodenum  and 
bury  it.  Tlie  diseased  segment  of  stomach  is  completely  severed  by  dividin"'  tlie 
stomach  Avith  an  electric  cautery  between  the  two  large  clamps.  A  loop  of 
jejunum  is  picked  up  about  eighteen  inches  from  the  beginning  of  the  jejunum 
and  is  carried  in  front  of  the  transverse  colon  and  omentum.  It  is  lonoitiidi- 
nalh^  clamped  with  a  long  rubber  covered  stomach  clamp  and  so  applied  to  the 
stump  of  the  stomach  as  to  make  the  distal  end  of  the  loop  approximate  the 
greater  curvature  of  the  stomach.  In  this  way  the  normal  peristalsis  of  the  je- 
junum would  go  from  tlie  upper  border  of  the  stomach  doAvnward  to  the  greater 


and    suU,?eH    tn   h3     t  i!       1^?    severed    at    its    cardiac    portion    and    a    loop    of    jejunum    is    brought    up 

of   the   stomach   In   fhl  ?n  J^'/   Penstaltic    curi^ent    in    the   jejunum    should    run    f/om    the    upper    border 

me   stomach   to   the   lower  border  as   indicated   by    the   arrows    (Polya-Balfour). 

curvature.  Two  interrupted  mattress  sutures  are  placed,  one  at  the  upper  and 
one  at  the  lower  border  of  the  stomach.  The  ends  are  left  long  so  they  may  be 
used  as  tractor  sutures.  The  loop  of  jejunum  is  united  to  the  posterior  wall  of 
the  stomach  by  a  continuous  right-angle  suture  of  silk  or  linen.  This  row 
is  applied  about  half  an  inch  behind  the  Payr  clamp  by  turning  the  clamp 
to  bring  this  part  of  the  posterior  stomach  wall  prominently  forward  (Fig. 
523).  After  these  sutures  are  inserted  a  long,  straight,  rubber  covered  clamp 
is  placed  on  the  stomach  about  two  inches,  if  possible,  from  the  Payr  crush- 


578 


OPERATIVE    SURGERY 


iiig  forceps.  The  Payr  clamp  is  removed  and  the  margin  of  the  stomach 
wall  which  was  crushed  with  the  Payr  clamp  is  trimmed  away  with  scissors, 
as  this  crushed  portion  will  not  make  a  satisfactory  union  and  may  cause  cica- 
tricial contraction.  A  slight  relaxation  of  the  pressure  of  the  stomach  clamp 
will  indicate  where  the  bleeding  points  are  to  be  controlled  with  interrupted 
catgut  sutures.  The  loop  of  jejunum  is  incised  along  its  convexed  border  in 
a  similar  manner  as  in  gastroenterostomy.  The  incision  should  not  be  quite 
as  long  as  the  wound  in  the  stomach.  The  jejunum  is  united  to  the  stomach 
in  the  same  manner  as  described  in  the  sleeve  resection;  that  is  by  begin- 


Fig.    S24. — The    second    row    of    sutures    is   placed    as    the    second    row    in    gastroenterostomy.      The    original 

first  row  is  then   continued  anteriorly. 

ning  a  tanned  or  chromic  catgut  suture  at  the  upper  margin  of  the  wound, 
clamping  the  short  end  of  the  suture,  and  uniting  the  posterior  margin  of 
the  gastric  wound  to  the  posterior  margin  of  the  wound  in  the  jejunum 
with  a  continuous  lock  suture  snugly  applied  (Fig.  524).  At  the  lower 
angle  of  the  wound  the  suture  is  continued  forward  as  a  right-angle  con- 
tinuous stitch  penetrating  all  coats  and  taking  a  small  margin  of  perito- 
neum. This  suture  may  be  locked  by  a  back  stitch  about  every  fourth  inser- 
tion of  the  needle.  Just  before  completing  the  suture  the  clamps  on  the 
stomach  and  jejunum  are  slightly  relaxed  to   demonstrate  if  there   is   any 


THE   STOMACH  579 

'"       '---  I 

marked  bleeding  point.  If  so,  it  is  controlled  by  interrupted  sutures  of  catgut. 
The  suture  is  then  completed  and  tied  to  the  original  end.  Another  row  of 
right  angle  sutures  of  silk  or  linen  is  phiced  and  at  the  upper  end  of  the 
■wound  an  extra  suture  is  applied.  The  stump  of  the  gastrohepatic  omentum 
is  drawn  over  the  wound  at  this  point  and  fixed  with  interrupted  sutures. 
The  lower  end  of  the  wound  is  similarly  protected. 

There  is  no  occasion  for  anastomosis  between  the  limbs  of  the  loop  of  jeju- 
num. The  loop,  of  course,  should  be  so  selected  as  to  put  no  tension  on 
the  bowel  at  any  point,  but  at  the  same  time  to  leave  no  marked  redundanc.y. 
Sometimes  the  wound  in  the  stomach  seems  abnormally  large,  and  this  may  be 
treated  in  one  of  several  ways.  The  opening  in  the  jejunum  may  be  made  not 
so  large  as  the  opening  in  the  stomach  and  the  excessive  amount  of  the  wound 
of  the  stomach  may  be  closed  or  sutured  to  the  unopened  part  of  the  jejunum. 
Eecently  C.  H.  Mayo  has  practiced  closing  the  lower  jjart  of  the  gastric  wound 
and  uniting  the  jejunum  to  the  upper  portion,  as  the  propulsive  waves  of  peris- 
talsis force  the  food  current  to  the  pylorus  along  the  lesser  curvature.  There 
seems  to  be  no  real  objection  to  a  large  opening^  however,  unless  there  is 
marked  dilatation  of  the  stomach  when  partial  closure  of  the  wound  before 
uniting  the  jejunum  to  it  can  be  made  according  to  the  method  of  C.  H.  Mayo. 

The  removal  of  foreign  bodies  may  demand  an  incision  into  the  stomach. 
This  is  usually  easily  accomplished.  The  stomach  is  incised  either  longitu- 
dinally, about  midway  between  the  greater  and  lesser  curvatures,  or  trans- 
versely. The  surrounding  tissues  are  protected  with  moist  gauze  and  the 
wound  is  closed,  preferably  by  the  method  described  after  excision  of  ul- 
cers or  pyloroplasty;  that  is  with  three  rows  of  sutures,  the  inner  row 
being  a  continuous  lock  stitch  of  fine  tanned  or  chromic  catgut  in  the  mucosa, 
the  next  a  simple  continuous  stitch  of  coarser  tanned  or  chromic  catgut,  and 
the  last  a  continuous  right-angle  suture  of  fine  catgut  including  the  peritoneum 
and  muscle. 

In  cancer  or  stricture  of  the  esophagus  it  may  be  necessary  to  do  a 
gastrostomy  to  keep  the  patient  from  starving  to  death.  This  may  be  done 
by  one  of  several  methods.  The  choice  of  operations  depends  to  some  ex- 
tent upon  the  local  conditions.  If  the  stomach  is  large,  Frank's  operation  is 
often  used.  An  incision  is  made  through  the  upper  part  of  the  left  rectus  mus- 
cle, the  fibers  of  the  muscle  being  split,  and  after  the  peritoneal  cavity  has 
been  opened  a  cone-shaped  piece  of  the  anterior  wall  of  the  stomach  is  brought 
well  into  the  wound.  The  base  of  the  cone  is  fixed  to  the  margins  of  the  pari- 
etal peritoneum  by  a  continuous  suture  of  silk.  A  second  incision  is  made 
about  parallel  to  the  costal  margin  and  an  inch  above  its  free  edge.  The  sub- 
cutaneous tissue  is  undermined  between  the  two  incisions  so  as  to  raise  a 
bridge  of  skin,  and  through  this  undermined  portion  the  tip  of  the  cone 
of  the  stomach  is  carried  until  it  reaches  the  second  incision.  It  is  here 
fixed  by  a  few  sutures   and  the   skin  of  the  original   abdominal  wound  is 


580 


OPERATIVE    STTRGERY 


completely  closed.  The  apex  of  the  cone  is  opened  and  a  tube  is  inserted.  This 
method  can  only  be  used  when  the  stomach  is  greatly  enlarged  and  even  then 
it  is  probaljly  inferior  to  the  other  tube  methods,  as  the  stomach  is  too  greatly 
fixed  and  its  motion  is  too  much  interfered  with  by  this  operation. 

In  the  Senn  method,  after  exposing  the  stomach  through  an  incision  about 
three  inches  long  through  the  outer  portion  of  the  left  rectus,  it  is  pulled 
into  the  wound.  Usually  the  stomach  is  small  and  retracts  under  the  mar- 
gins of  the  ribs.  A  point  on  its  anterior  border  is  selected  for  the  insertion 
of  a  tube.  This  should  be  about  midway  between  the  lesser  and  greater  curva- 
tures and  as  near  the  cardiac  end  as  possible.  This  point  is  pulled  well  into 
the  wound  and,  after  protecting  the  surrounding  tissues  with  moist  gauze  to 
prevent   soiling,   a   small  incision  is   made   into   the   stomach.      Through   this 


Fig.    525. — Gastrostomy,    according   to    the    Senn   method. 


opening  a  large-sized  soft  rubber  catheter  with  an  extra  perforation  near 
its  eye  is  inserted  and  passed  toward  the  pylorus  for  two  or  three  inches. 
The  tube  is  fixed  in  position  by  a  tanned  or  chromic  catgut  suture  which 
surrounds  the  margin  of  the  opening  and  also  takes  a  bite  in  the  tube. 
This  suture  is  tied  and  a  series  of  pursestring  sutures  of  linen  or  silk  is  passed 
in  concentric  circles  in  the  stomach  Avail  around  the  tube  (Fig.  525).  The 
first  of  these  is  half  an  inch  from  the  tube  and  as  the  suture  is  being- 
tied  the  tube  is  shoved  in,  so  making  an  inverted  cone.  The  second  purse- 
string  suture  is  about  a  quarter  of  an  inch  from  the  preceding  suture 
and  is  passed  and  tied  in  the  same  manner.  Three  or  four  such  sutures  are 
applied.  The  stomach  is  anchored  to  the  parietal  peritoneum  by  sutures 
above  and  below  the  tube  and  the  abdominal  incision  is  closed  in  layers, 
allowing  the  tube  an  exit.  Six  or  seven  ounces  of  peptonized  milk  may  be 
given  on  the  operating  table.     The  tube  is  clamped  after  the  feeding.     The 


THE    STOMACH  581 

jitiictioii  fil"  a  1ul)c  inserted  in  this  way  is  Avater  tight  and  Ihe  elanip  is  only 
removed  Avlien  a  feeding-  is  given. 

In  the  Witzel  o]>eration  a  tube  is  introduced  in  much  the  same  manner  as 
in  llie  Senn  method  and  fixed  by  sutures,  but  the  tube  is  buried  by  suturing 
the  wall  of  the  stoma  eh  over  the  tube  so  that  the  tube  lies  in  a  groove  or  furrow 
instead  of  in  the  middle  of  a  cone.  These  sutures  are  interrupted  and  of  silk 
or  linen  (Fig.  526).  The  stomach  is  fixed  to  the  abdominal  wall  in  a 
similar  inanner  to  that  described  after  the  Senn  gastrostomy. 

Eesection  of  the  whole  stomach  for  cancer  and  anastomosis  of  the  jejunum 
to  the  esophagus  either  according  to  the  "Y"  technic  of  Roux  or  bringing  up  a 
jejunal  loop  is  possible.  Excision  of  the  whole  stomach  has  been  done  but 
indications  for  such  an  operation  are  exceedingly  rare.  If  it  is  necessary  to 
remove  all  of  the  stomach  to  eradicate  malignant  disease,  it  is  highly  prob- 


Fig.  526. — Gastrostomy  according  to  the  method  of  Witzel. 

able  that  metastases  elsewhere  have  occurred  to  such  an  extent  as  to  make 
the  radical  operation  of  complete  gastrectomy  exceedingly  unlikely  to  cure. 

In  complete  occlusion  of  the  lower  end  of  the  esophagus,  operations  have 
been  devised  by  which  a  tube  is  made  from  a  flap  of  the  stomach  taken  from 
the  greater  curvature  and  so  shaped  that  it  has  an  abundance  of  nourishment. 
This  flap  is  fashioned  by  sutures  into  a  tube  and  is  brought  up  beneath  the 
skin  and  connected  by  a  rubber  tube  with  the  esophagus  in  the  neck.  The 
operation  has  not  been  tried  out  sufficiently  to  have  a  good  standing  in  surgi- 
cal operations,  but  in  certain  rare  instances  it  might  be  considered. 

A  peculiar  condition  of  the  pyloric  end  of  the  stomach,  known  as  congeni- 
tal p^doric  stenosis,  occasionally  occurs.  This  is  usually  observed  in  infants 
from  one  to  four  weeks  after  birth.  It  consists  of  a  great  hypertrophy  of 
the  muscular  coats  of  the  pylorus  and  the  adjacent  portion  of  the  stomach. 


582 


OPERATIVE    SURGERY 


The  hypertrophy  is  so  great  as  to  form  a  tumor  Avhich  sometimes  can  be 
palpated  externally.  The  marked  projectile  vomiting  and  the  characteris- 
tic visible  peristaltic  waves  of  the  stomach,  together  w^ith  the  peculiar  worm- 
like peristalsis  of  the  pyloric  end  which  has  been  noted  by  A.  A.  Strauss 
under  fluoroscopic  examination,  make  the  diagnosis  reasonably  certain.  The 
necessity  of  an  operation  dej^ends  upon  the  degree  of  the  stenosis.  For- 
merly these  cases  were  operated  upon  by  a  posterior  gastroenterostomy  which 
carried  a  rather  high  mortality,  but  the  operation  of  Rammstedt  is  better.  This 
consists  in  incising  the  hypertrophied  pyloric  fibers  down  to  the  mucosa,  but  the 
mucosa  itself  is  not  incised.     The  margins  of  the  severed  hypertrophied  mus- 


i^ig.   S27. — The   operation    of   Rammstedt   for   congenital    pyloric    stenosis.      The   hypertrophy   is   carefully   in- 
cised almost  to  the  mucosa  and  the  margins  of  the  wound  are  pushed  apart  as  shown  in  the  illustration. 


cle  fibers  are  pushed  apart  by  spreading  the  blades  of  a  forceps  (Fig.  527). 
This  operation,  which  is  done  through  a  short  right  rectus  incision,  can  be 
quickly  performed  and  the  results  are  a  distinct  improvement  over  the  results  ob- 
tained by  gastroenterostomy. 

A.  A.  Straass^^  has  devised  an  operation,  which,  in  his  hands,  has  given 
excellent  results  with  a  mortality  of  only  three  deaths  in  one  hundred  and 
three  consecutive  eases.  This  operation  is  based  on  experimental  work  done  by 
Strauss  in  1912  and  1913'.  According  to  his  technic  an  incision  about  one  inch 
long   is   made   through  the   fibers   of  the   rectus   muscle   in   the   right   hypo- 


i-Surgical   Clinics  of   Chicago,   Feb.,    1920,   Philadelphia,   W.    B.    Saunders   Co.,   93,   et   seq. 


THE    STOMACH 


583 


chondriac  region  over  the  pylorus.  Often  a  tumor  can  be  felt  which  ren- 
ders the  location  of  the  incision  more  accurate.  The  index  finger  is  in- 
serted through  the  incision  and  a  ribbon-shaped  hook  is  introduced  into 
the  Avound  nlong  the  index  finger  to  the  hypertrophied  pylorus  which  is 
brought  up  into  the  wound  by  this  hook.  If  this  cannot  be  readily  done 
or  a  hook  of  this  type  is  not  available,  the  incision  may  be  enlarged  until 
the  i^ylorus  can  be  delivered  into  the  wound  without  difficulty.  The 
practice  of  Strauss,  however,  is  to  deliver  the  pylorus  by  this  hook,  working 
through  a  small  incision  in  order  to  avoid  unduly  exposing  the  other  por- 
tions of  the  stomach  or  the  intestines.  After  delivering  the  tumor,  which  con- 
sists of  the  hypertrophied  pylorus,  an  incision  is  made  in  the  more  bloodless 
region  of  the  pylorus.  This  incision  is  longitudinal  and  is  made  with  a  sharp 
knife,  going  through  only  the  superficial  layers  of  the  hypertrophied  muscle. 
The  rest  of   the   fibers   are   separated  with  the  handle   of   a   scalpel   to   the 


Fig.   528. — Operation  for  congenital  pyloric  stenosis  according  to   Strauss.     The  mucosa  is  mobilized  around 

its  entire  circumference. 


stomach  side  of  the  growth  where  it  merges  into  the  normal  musculature 
of  the  stomach.  Working  to  the  mucosa  of  the  stomach  in  this  manner 
and  in  this  region  gives  a  line  of  cleavage  between  the  mucosa  and  the  mus- 
cular coat  that  is  easily  obtained  and  makes  it  possible  to  split  down  the 
hypertrophied  muscle  to  the  duodenum  without  the  accident  of  punctur- 
ing the  mucosa  of  the  duodenum,  which  is  a  very  grave  danger  in  the  usual 
method  of  performing  the  Rammstedt  operation  (Fig.  528).  The  edges  of  the 
divided  hypertrophied  muscle  fibers  are  caught  and  pulled  apart  with  the  fin- 
gers and  thumb,  using  a  piece  of  gauze  to  secure  a  firm  hold.  This  causes 
the  mucosa  to  separate  from  the  muscular  coats  in  the  stomach  and  also 
breaks  the  few  remaining  muscle  fibers  toward  the  duodenal  end.  These 
fibers  are  often  responsible  for  constriction  and  when  divided  with  a  knife 
injury  to  the  mucosa  of  the  duodenum  is  likely  to  occur.  By  this  method 
they  are  torn  apart  instead  of  being  cut.     The  mucosa  is  completely  shelled 


584 


OPERATIVE    SURGERY 


out  by  blunt  dissection  from  the  muscular  layers  of  the  hypertrophied  py- 
lorus. This  causes  the  mucosa  to  unfold.  Strauss  completes  the  operation 
by  splitting  a  flap  from  the  inner  portion  of  the  hypertrophied  muscle  fi- 
bers as  shown  in  the  illustration.  This  flap  hinges  along  one  edge  of  the 
incision  and  is  turned  over  the  exposed  mucosa  and  fastened  with  a  few  inter- 
rupted sutures  of  fine  silk  to  the  other  edge  of  the  incision  (Fig.  529).  This 
covers  the  mucosa  completely.  The  free  end  of  the  omentum  is  brought  over 
the  flap  and  sutured  in  position.  A  cross  section  of  the  completed  operation 
shows  a  lumen  well  established  with  the  mucosa  distended  and  at  the  same 
time  protected  in  its  anterior  portion  by  the  flap  which  has  been  cut  from 
the  hypertrophied  muscle  (Fig.  529-A).  The  method  of  completely  mobiliz- 
ing the  mucosa  Avithout  the  danger  either  of  perforation  of  the  duodenal 
mucosa  or  of  leaving  a  few  obstructing  flbers,  presents  two  great  advantages, 
the  lack  of  which  has  been  responsible  for  most  of  the  deaths  after  the 
llammstedt  operation. 


Fig.   529. — Operation  for  congenital   pyloric  stenosis.      A  flap   from  the   hypertrophied  tissue   is  made   and   is 
sutured  in  position.     Insert  A   shows  a   cross  section  of  the  completed   operation   (Strauss). 

Occasionally  for  a  local  lesion  a  resection  of  the  pylorus  is  indicated 
which  may  be  so  limited  in  character  as  to  permit  the  union  of  the  duo- 
denum to  the  stomach.  If  this  can  be  accomplished  the  union  may  be  done 
according  to  the  original  method  of  Billroth  in  Avhich  the  duodenum  is  su- 
tured to  the  Avound  at  the  lower  border  of  the  stomach  and  the  upper  por- 
tion of  the  stomach  wound  is  closed.  Or  the  duodenum  may  be  inserted 
into  the  posterior  w^all  of  the  stomach  a  short  distance  behind  the  line  of 
incision  in  the  stomach.  This  latter  method  of  Kocher  is  probably  less  likely 
to  be  folloAved  by  leakage  at  the  line  of  union  of  the  duodenum  and  stomach 
than  is  the  method  of  Billroth,  though  the  danger  of  leakage  in  Billroth 's 
original  operation  can  be  greatly  lessened  by  reinforcing  the  line  of  union 
with  a  transplanted  flap  of  omentum. 


CHAPTER  XXVI 

OPERATION  ON  THE  INTESTINES 

THE  TECHNIC  OF  SUTURING  WOUNDS  OF  THE  STOMACH  AND 

INTESTINES 

The  technic  of  suturing  the  stomach  and  intestines  varies  consideraljly 
because  of  the  difference  in  the  anatomical  structures  of  these  organs,  as 
"well  as  in  the  nature  of  their  physiologic  action.  The  stomach  is  a  large 
organ  with  a  very  thick  muscular  wall  that  consists  of  several  layers  of 
muscular-  fibers  running  in  different  directions.  The  intestinal  wall  is  much 
thinner  and  has  only  two  layers  of  muscle,  the  external  being  longitudinal  and 
the  internal  circular.  The  great  thickness  of  the  gastric  wall  together  with  its 
peculiar  churning  and  propulsive  motions  produces  considerable  strain  upon  a 
sutured  incision  in  the  stomach.  The  much  greater  tendency  to  ulceration  in 
the  stomach  than  in  the  intestines,  particularly  in  the  small  intestine,  must  also 
be  taken  into  consideration.  Suture  material  should  be  provided  for  the  stom- 
ach that  will  not  remain  as  a  permanent  foreign  body  to  become  a  focus  of 
infection  or  the  site  of  an  ulcer.  In  the  intestine  sutures  appear  to  work 
into  the  lumen  more  readily  than  in  the  stomach,  possibly  because  the  walls 
are  thinner  and  the  peristalsis  is  usually  in  a  direction  that  tends  to  drag 
any  projecting  portion  of  the  sutures  along  with  the  feeal  current.  Sutures 
of  the  stomach,  then,  should  usualh'  be  of  absorbable  material  and  as  the  wall  is 
thick,  and  as  the  action  of  the  gastric  juice  may  quickly  disintegrate  plain 
catgut,  the  absorbable  suture  should  be  well  tanned  or  chromicized.  There 
should  always  be  at  least  two,  and  better,  three  layers  of  sutures.  The 
first  layer  unites  the  mucosa  with  a  continuous  lock  stitch  that  merely  ap- 
proximates the  edges  of  the  mucosa.  This  is  No.  0  tanned  or  chromic  catgut. 
The  second  layer  brings  together  the  muscular  coats  and  the  edges  of  the 
peritoneum  on  one  side  to  similar  structures  on  the  other,  using  a  larger 
size  of  the  same  suture  material.  The  third  layer  is  a  continuous  right-angle 
suture  of  00  tanned  or  chromic  catgut.  It  is  well  to  take  a  back  stitch  at 
about  every  fourth  insertion  of  the  needle  when  using  a  right-angle  continuous 
suture  as  this  locks  the  line  of  sutures  and  prevents  tension  on  the  thread 
from  acting  as  a  basting  suture  and  drawing  the  tissues  too  tightly  together. 

AVhen  clamps  are  used,  however,  the  method  of  suturing  the  stomach 
with  these  three  layers  is  not  practicable.  With  clamps,  as  in  resection  of 
the   stomach   or   in   gastroenterostomy,   the    posterior   borders    are   first   united 

5S5 


586  OPERATIVE    SURGERY 

by  a_  peritoneal  and  musenlar  sntnre  which  is  the  first  row  that  is  placed.  This 
may  be  of  fine  00  tanned  or  chromic  catgut  and  is  inserted  with  a  curved 
or  straight  needle  in  gastroenterostomy.  In  resection  of  the  stomach  for  can- 
cer, however,  the  healing  of  the  tissues  is  at  a  very  Ioav  ebb  and  it  is  prol)alily 
wiser  to  use  for  the  outer  row  silk  or  linen  which  will  hold  longer  than  cat- 
gut, even  though  there  may  be  a  chance  of  the  unabsorbal)le  material  being 
retained  in  tlie  wall  of  the  stomach.  Wlien  clamps  are  used  in  stomach  sur- 
gery the  posterior  row  of  sutures  uniting  the  peritoneum  may  be  either  continu- 
ous as  in  gastroenterostomy,  or  interrupted  mattress  sutures.  The  second  or  in- 
ner row  is  always  a  continuous  suture,  usually  a  lock  stitch  on  the  posterior  wall, 
penetrating  all  coats  and  is  snugly  applied  and  of  size  No.  1,  tanned  or  chromic 
catgut.  After  completing  the  posterior  sutures  as  a  lock  stitch  it  is  best  to  change 
into  a  right-angle  stitch,  penetrating  all  coats,  and  taking  short  bites  through 
the  whole  wall  of  the  stomach.  This  is  drawn  snugly  and  is  continued  around 
the  anterior  wall.  The  clamps  should  be  slightly  loosened  just  before  the 
sutures  are  completed  to  demonstrate  any  bleeding  jjoints.  The  suture  is 
tied  to  the  original  short  end.  The  roAV  first  begun  is  then  completed,  so 
burj'ing  the  inner  row  throughout.  It  is  important  to  put  extra  sutures  at 
each  end  of  the  incision  in  order  to  take  up  the  strain  that  occurs  at  these 
points. 

After  gastroenterostomy  the  tissues  of  the  jejunum  usually  have  low 
vitality  because  they  are  subjected  to  unphysiologic  conditions  which  have 
already  been  discussed.  Here  the  acid  contents  of  the  stomach  empties 
into  the  jejunum  which,  normally,  contains  only  an  alkaline  medium.  This 
effect  may  be  partly  obviated  if  the  pylorus  remains  permanently  closed,  but 
in  any  event  a  trauma  or  a  source  of  irritation  at  this  point,  such  as  the 
application  of  clamps  during  the  performance  of  the  operation,  or  the  pres- 
ence of  silk  or  linen  sutures,  may  be  too  great  a  burden  for  these  tis- 
sues to  carry  when  they  are  already  struggling  against  abnormal  condi- 
tions. Consequently,  a  suture  or  a  trauma  that  in  normal  tissue  could  be 
readily  disposed  of,  may  cause  trouble  here.  In  other  portions  of  the  in- 
testinal tract  there  seems  to  be  but  little  objection  to  the  use  of  unabsorb- 
able  suture  material. 

In  the  small  bowel  a  single  row  of  unabsorbable  sutures  if  properly 
placed  is  safe.  More  than  this  tends  to  occlude  the  lumen  of  the  bowel. 
In  the  large  intestine  because  of  irregularities  of  its  external  surface  and 
the  solid  character  of  the  fecal  matter  which  produces  a  greater  strain  upon 
the  wound,  it  is  best  to  use  an  inner  row  of  nonabsorbable  sutures  and  to 
reinforce  this  by  another  row  of  sutures,  preferably  interrupted  fine  tanned 
or  chromic  catgut.  All  sutures  for  the  intestine  or  stomach  should  be  placed 
in  a  round  noncutting  needle.  For  resection  of  the  small  bowel  a  straight  or- 
dinary needle,  rather  long,  the  kind  usually  called  a  "milliner's  needle,"  is 
excellent.  Linen  or  silk  is  used.  If  silk  is  used  it  should  have  ample 
tensile  strength.  Linen,  though  somewhat  rougher,  is  stronger  than  silk. 
The  needles  are  threaded  with  a  silk  or  linen  strand  about  eighteen  inches 


THE   INTESTINES  587 

loiii^'  jiiul  four  of  tliese  llircaded  needles  are  worked  Ihroiigli  a  strip  of  gauze, 
such  as  a  piece  of  bandage  two  feet  long.  This  prevents  tangling  of  the 
thread.  The  use  of  a  thimble  with  a  straight  needle  is  readily  acquired 
and  adds  somewhat  to  the  efficiency  of  the  technic.  It  also  lessens  the  lia- 
bility of  puncturing  the  glove.  Where  the  bowel  cannot  be  readily  delivered 
or  where  the  amount  of  fat  is  excessive,  a  straight  needle  cannot  be  used 
satisfactorily  and  a  curved  needle  is  employed.  The  sutures  are  inserted 
through  all  coats  of  the  boAvel.  It  has  been  demonstrated  first  by  W.  S. 
Halsted  that  an  intestinal  suture  that  does  not  take  at  least  a  part  of  the 
submucosa  of  the  intestine  is  unsafe  and  is  likely  to  tear  out.  F.  G. 
Coiinell  showed  the  difficulty  of  catching  any  portion  of  the  submucosa  in  the 
bite  of  the  needle  without  penetrating  to  the  mucosa.  If  the  safety  of  the 
intestinal  suturing  is  dependent  upon  grasping  the  submucosa  in  its  bite, 
it  would  be  best  to  be  certain  of  this  and  to  make  an  effort  to  penetrate  to 
the  lumen  of  the  bowel  with  the  insertion  of  each  stitch. 

Lambert  first  demonstrated  the  necessity  of  broad  approximation  of 
the  peritoneal  coats  in  intestinal  suturing.  The  so-called  Lambert's  suture 
was  originally  said  to  be  a  suture  of  the  peritoneum  alone,  but  this  is  im- 
possible. As  has  alreadj^  been  pointed  out  it  is  necessary  to  secure  firm 
union,  particularly  if  only  one  row  of  sutures  is  to  be  used,  and  to  do  this 
there  must  be  penetration  into  the  lumen  of  the  bowel  with  each  suture. 
This  should  be  done,  hoAvever,  in  such  a  manner  as  to  invert  the  edge  of 
the  intestinal  wound  and  to  bring  together  snugly  the  peritoneal  surfaces  as 
called  for  by  Lambert. 

The  two  types  of  intestinal  sutures  are  interrupted  and  continuous.  All, 
of  course,  must  embody  the  Lambert  principle  of  inverting  the  edges  of  the 
bowel  and  approximating  the  peritoneal  coat.  No  more  of  the  bowel  edge 
should  be  turned  in  than  is  necessary  to  secure  a  neat  approximation  of 
the  wound.  If  too  much  is  turned  in,  particularly  in  circular  suturing, 
too  great  a  diaphragm  may  be  produced  and  obstruction  will  result.  Then, 
an  unnecessary  amount  of  tissues  is  placed  Avithin  the  lumen  of  the  bowel 
which  adds  to  the  burden  of  tissue  repair. 

Different  emergencies  may  call  for  different  types  of  suturing  but,  as 
a  rule,  if  interrupted  sutures  are  used  they  should  preferably  be  of  the  mat- 
tress type.  This  holds  with  a  firm  grip  and  is  not  likely  to  cut  out.  There  is 
an  objection  that  more  nutrition  is  cut  off  from  the  edge  of  the  wound 
by  the  interrupted  mattress  sutures  than  by  the  single  straight  suture.  If 
the  sutures  are  not  placed  too  close  together  and  are  not  tied  too  tightly 
this  disadvantage  may  be  overcome.  The  tying  of  any  intestinal  suture  is  a 
matter  of  great  importance.  The  tying  of  sutures  in  the  skin  or  fascia  may 
merely  result  in  an  ugly  defect  in  that  portion  of  the  wound,  but  an  improp- 
erly tied  intestinal  suture  may  cause  leakage  of  the  bowel  with  death. 
If  the  tissues  are  not  snugly  approximated,  leakage  may  occur  around 
the  suture,  but  an  equal  or  even  greater  danger  is  that  if  the  suture  is 
too  tight  and  the  nutrition  within  its  grasp  is  completely  cut  off  the  bowel 


588  OPERATIVE    SURGERY 

wall  Avill  become  necrotic  "within  the  bite  of  the  suture  and  leakage  is 
very  apt  to  follow.  In  experimental  work  an  operator  who  first  attempts 
intestinal  suturing  is  likely  to  commit  the  error  of  tying  the  sutures  too 
tightly.  It  often  happens  that  leakage  occurs  at  points  where  he  is  most 
particular  to  make  the  suture  secure  and  not  only  destroys  the  nutrition  of 
the  tissues  but  acts  as  a  seton  and  drains  the  intestinal  contents  into  the  peri- 
toneal cavity. 

The  dangers  from  intestinal  suturing  may  be  placed  in  the  ratio  of  their 
importance;  first,  tying  the  suture  too  tightly;  second,  not  tying  the  suture 
tightly  enough ;  and  third,  turning  in  too  much  bowel.  This  last  danger,  of 
course,  presupposes  that  each  suture  has  been  otherwise  properly  placed  and 
penetrates  into  the  lumen  of  the  intestine.  Occasionally,  as  a  reinforcing 
stitch  a  simple  continuous  suture  is  all  that  is  necessary,  but  if  dependence 
is  to  be  put  on  a  single  row  of  intestinal  sutures,  the  mattress  sutures,  par- 
ticularly the  continuous  mattress,  offers  many  advantages.  This  is  the  same 
as  the  continuous  right  angle  suture.  Applied  from  within  the  lumen  of  the 
bowel,  as  in  the  first  portion  of  suturing  after  a  resection,  it  is  usually  called 
a  mattress  suture,  but  when  applied  from  the  peritoneal  surface  as  in  the 
later  stages  of  suturing  a  resection,  it  is  often  referred  to  as  a  right  angle 
stitch.  The  mechanical  effect  of  both  is  identical  though  the  technic  of  in- 
sertion may  be  different.  The  bite  of  the  needle  is  parallel  with  the  edge  of 
the  wound,  so  that  the  visible  part  of  the  suture  on  the  external  portion  of 
the  wound  is  at  a  right  angle  to  the  wound,  hence  the  name. 

The  advantages  of  this  type  of  sutures  are  several.  First,  there  is  a 
firmer  grip  upon  the  tissues.  In  a  simple  continuous  overhand  stitch  the  bite 
of  the  needle  is  at  a  right  angle  to  the  wound.  Consequently,  the  tension 
on  the  thread  is  concentrated  at  that  portion  of  its  bite  which  is  farthest  from 
the  intestinal  Avound.  This  cencentrated  tension  may  produce  cutting.  In 
the  continuous  mattress-  or  right-angle  stitch  the  tension  is  more  or  less  equally 
distributed  along  the  whole  length  of  the  loop.  It  is  common  knowledge 
that  in  suturing  such  friable  material  as  a  muscle  a  mattress  suture 
that  distributes  pressure  approximately  equally  along  the  loop  will  hold 
when  a  straight  stitch  will  cut  out.  The  same  principle  applies  here.  An- 
other advantage  is  that  the  thread  is  more  easily  buried.  After  a  properly 
applied  right  angle  suture  the  thread  is  often  invisible  except  possibly  at 
the  beginning  or  end  of  the  suture,  and  sometimes  the  knots  can  be  buried. 
In  the  continuous  overhand  suture,  however,  there  is  always  a  considerable 
amount  of  the  thread  showing  along  the  suture  line.  It  is  necessary  to  pene- 
trate the  lumen  of  the  boAvel  in  order  to  secure  a  firm  hold  for  the  sutures 
and  the  effect  of  capillarity  must  be  borne  in  mind.  A  method  of  suturing 
that  results  in  the  burying  of  most  of  the  thread  in  the  peritoneal  coat  has 
obvious  advantages  in  this  respect  over  a  method  in  which  much  of  the  thread 
is  exposed  and  where,  consequently,  septic  material  may  drain  by  capillarity 
from  the  lumen  of  the  bowel  to  the  peritoneal  surface. 


THE   INTESTINES  589 

-As  ;i  rule.  ;i  coiil  iniKnis  siiluri'  is  ])r('i'er;il)le  to  an  interrupted  though^  of 
course,  there  is  a  field  for  both.  The  interrupted  mattress  suture,  particu- 
larly, cuts  off  more  nutrition  from  the  edge  of  the  healing  wound  than  does 
a  continuous  mattress,  because  the  interrupted  mattress  diminishes  nutrition 
to  the  approximated  portions  of  the  bowel  within  the  grasp  of  the  suture 
on  both  sides  of  the  intestinal  wound;  whereas  in  a  continuous  mattress  or 
right-angle  suture  the  tissue  on  the  opposite  side  to  the  bite  of  the  suture  is 
free  from  constriction  and  its  circulation  is  not  iiupaired. 

Crile  has  had  much  success  with  a  double  mattress  or  cobbler's  stitch. 
This  stitch  should  be  applied  with  great  care  for  if  drawn  too  tightly  it  will 
cut  off  a  maximum  amount  of  nutrition  from  the  healing  wound.  It  gives 
an  even  support  to  the  wound  and  in  highly  vascular  tissue  it  is  very  satis- 
tactoTy. 

Aside  from  the  question  of  nutrition  further  advantages  of  a  contin- 
uous suture  over  an  interrupted  are  that  the  former  produces  a  mild 
pressure  on  the  peritoneum  along  the  whole  surface  of  the  approximated  in- 
testinal wound,  and  it  holds  the  wound  at  rest  like  a  splint.  With  inter- 
rupted sutures,  however,  the  pressure  is  greatest  in  the  grip  of  the  suture, 
very  slight  in  the  intervals  between  the  sutures,  and  there  is  no  splint- 
like action.  The  bowel  wall  can  distend  and  contract  with  the  alternate 
relaxation  and  contraction  of  each  peristaltic  wave  and  this  constant  motion 
maj"  retard  healing.  The  action  of  the  continuous  sutures  which  holds  the 
wound  of  the  bowel  as  in  a  splint  and  prevents  the  alternate  distention  or 
contraction  is  a  very  obvious  advantage  in  healing. 

Small  intestinal  wounds  are  best  treated  with  one  or  tw^o  interrupted 
sutures,  or  with  a  pursestring  suture  that  inverts  the  edges  of  the  wound 
and  that  can  be  applied  in  small  wounds  where  the  inversion  is  not  suffi- 
cient to  interfere  seriously  with  the  lumen  of  the  bowel. 

Wherever  possible  in  suturing  the  bowel  intestinal  clamps  should  be  ap- 
plied at  some  distance  from  the  site  of  operation  to  prevent  soiling  the 
wound.  If  clamps  are  unavailable  tapes  or  strips  of  gauze  may  be  utilized 
by  perforating  the  mesentery  with  a  blunt  forceps  at  a  short  distance  from 
the  bowel  and  tying  the  tapes  snugly.  Care  should  be  taken  to  use  no  more 
pressure  than  necessary  to  occlude  the  lumen.  Another  method  is  afforded 
through  the  use  of  hemostatic  forceps  which  are  thrust  through  the  mesentery 
and  a  rubber  tube  is  grasped  in  the  tip  of  the  forceps.  The  forceps  are  locked 
and  the  tube  is  fastened  to  the  handle  of  the  forceps  in  such  a  manner  as  to 
produce  occlusion  of  the  lumen  of  the  bowel.  Two  wooden  tongue  depressors 
and  electric  bands  may  be  employed. 

ENTEROSTOMY 

J.  W.  Long,  of  Greensboro,  N.  C,  has  been  a  pioneer  in  pointing  out 
the  life  saving  value  of  a  simple  enterostomy  performed  before  the  patient 
has  become  overwhelmed  with  the  toxic  products  of  an  intestinal  obstruc- 
tion. 


590 


OPERATIVE    SURGERY 


When  obstruction  follows  shortly  after  operation  and  the  resistance 
of  the  patient  has  already  been  greatly  reduced,  Long^  operates  after  re- 
moving one  or  two  stitches  of  the  wound.  The  point  of  obstruction  is  not 
searched  for  unless  it  is  easily  reached,  but  the  first  distended  coil  of  intes- 
tine is  delivered  into  the  wound  and  a  pursestring  suture  is  placed  deep  in 
the  bowel  wall  encircling  an  area  at  least  one-half  an  inch  in  diameter.  The 
suture  is  caught  at  two  points  with  forceps  and  the  untied  ends  are  grasped 
with  the  lingers.  By  making  traction  on  the  forceps  and  on  the  untied 
ends  sufficient  tension  is  made  to   steady  the  wall   of  the   bowel   and   also 


''  A 


Fig.   530. — Enterostomy  of  J.   W.  Long.     A  pursestring  suture  has   been  placed  and  the  bowel  is  perforated 

with  the  cautery. 


to  reduce  the  soiling  of  the  field  of  operation.  The  coil  of  intestine 
is  lightly  packed  around  with  moist  gauze  and  Avliile  the  ends  of  the  su- 
ture and  the  two  forceps  which  grasp  the  other  portion  of  the  suture  are 
held  taut,  the  center  of  the  area  that  is  circumscribed  by  the  pursestring 
suture  is  perforated  with  a  thermo  cautery  (Fig.  530).  This  prevents  bleed- 
ing and  seals  the  various  coats  of  the  intestine  together.  It  also  prevents  a 
tendency  to   eversion  of  the  mucosa  which  occurs  after  an  incised  wound. 


■■■Tr.  Southern  Surg.  Assn.,  xxix,  p.  59,  et  seq. 


THE    INTESTINES 


591 


A  tube,  which  should  he  ready,  is  inserted  immediately  after  the  cautery 
point  is  Avithdrawii.  The  tube  is  of  fairly  soft  rubber  that  will  not  readily 
collapse  and  should  be  about  twice  the  size  of  the  opening.  It  is  intro- 
duced with  forceps,  stretching  the  perforation  if  necessary,  and  fits  so  snugly 
that  there  is  no  leakage  around  it.  The  two  forceps  are  removed  from 
the   pursestring   suture   and   the   ends   of  the   suture   are   tied   snugly  after 


Fig.   531. — A  rubber  tube   is  introduced   and  held  snugly  by  a  pursestring  suture.      Insert  A   shows  a  cross 
section   of  tube   in  position,  and   insert  B   shows   omentum   sutured  around  the   tube    (J.   W.   I,ong), 

carefully  inverting  the  edges  of  the  perforation.  Sometimes  a  second  purse- 
string suture  may  be  added,  as  in  the  Senn  gastrostomy.  If  omentum  is 
present  it  is  either  drawn  around  the  tube  and  held  in  position  by  a  few 
catgut  sutures,  or  a  hole  may  be  torn  in  it  and  the  tube  brought  through 
the  omentum  which  is  fastened  to  the  bowel  on  each  side  of  the  tube  (Fig. 
531).  He  objects  to  fastening  the  tube  in  position  by  suturing  it  to  the  bowel 
w^all,  for  he  says  that  the  suture  will  cut  through  the  bowel  Avail,  in- 
crease the  size  of  the  opening  into  the  intestine,  and  make  the  fecal  fistula 


59f 


OPERATIVE    SURGERY 


more  difficult  to  close  by  promoting  eversion  of  the  mucosa.  Long  fastens 
the  tube  by  narroAv  strips  of  adhesive  plaster  from  the  tube  to  the  skin. 
(Fig.  532).  The  open  part  of  the  al)doniinal  wound  is  lightly  packed  M'ith 
gauze.  Sometimes  the  loop  of  l)0\\el  may  l)e  anchored  to  the  parietal  peri- 
toneum by  two  or  three  interrupted  sutures,  ]}ut  this  is  not  always  necessary. 
AVhen  the  operation  does  not  admit  of  the  delivery  of  a  coil  of  in- 
testine into  the  Avound  the  operation  of  J.  W.  Long  is  an  excellent  one 
and  has  many  advantages.  When  the  bowel  can  be  readily  delivered 
and  pac]\ed   off,  I  j^refer  an   operation  based   on  a  principle   estal)lished   by 


Fig.    532. — The   wound   is   packed   lightly   with   gauze    and   the    tube    fastened    with    adhesive   plaster 

(J.    W.    Long). 

Coffey  of  making  a  valve  of  the  mucosa  of  the  bowel,  so  that  when  the 
tube  is  withdrawn  there  will  be  but  little  if  any  leakage.  A  distended  loop 
of  bowel  is  delivered  into  the  wound,  clamped  at  one  end  with  intestinal 
forceps,  stripped  of  its  contents,  and  again  clamped  at  a  point  about  six 
inches  from  the  first  intestinal  forceps.  The  convex  border  of  the  intestine 
is  grasped  with  mosquito  forceps  or  with  Allis  forceps  about  two  inches 
from  one  of  the  clamps  and  another  point  is  similarly  caught  tAvo  inches  from 
the  other  intestinal  clamp.  The  forceps  holding  these  tAvo  points  are  pulled 
upon  just  enough  to  make  the  boAvel  betAveen  them  taut,  and  a  tAvo  inch  in- 


THE    INTESTINES 


593 


eisioii  is  iiuidc  in  1lie  axis  of  tlic  l)()\v('l  1)o1ween  them.  This  should  be 
made  Avilli  a  sharp  Iviiifo  and  care  must  be  taken  not  to  cut  through  the 
nuuMisa.  After  separating  the  peritoneum  and  the  superficial  part  of  the 
muscular  coat  of  the  bowel  the  edges  of  the  incised  wound  are  i^ushed 
apart  with  the  handle  of  the  knife  or  by  dissecting  with  the  blade  of  the 
knife  turned  sidewise  to  the  plane  of  dissection,  which  is  a  stroke  often  em- 
ployed in  operations  on  the  neck  and  in  anatomical  dissections.  In  this 
way,  even  tlunigh  the  bowel  wall  is  thin,  injury  to  the  mucosa  can  usually 
be  avoided.  Considerably  more  care  must  be  taken,  hoAvever,  to  avoid  in- 
jury to  the  mucosa  than  in  making  a  similar  incision  into  the  stomach.  If  the 
mucosa  is  injured  at  either  end  of  the  incision  but  little  harm  is  done.  If, 
hoAvever,  it  is  injured  at  its  middle,  the  incision  should  be  extended  slightly 


Fig.    533. — Enterostomy,    using    the    principle    of    Coffey.      An    incision    is    made    down    to    the    mucosa.      At 
one   end  of  the  incision  a  pursestring  suture  is  inserted  and  the  mucosa   is  punctured. 


at  one  end  in  order  to  secure  a  sufficient  amount  of  exposed  mucosa  to 
form  a  valve.  If  the  mucosa  has  not  been  injured  and  has  been  exposed 
over  a  distance  of  about  two  inches,  a  pursestring  suture  of  linen  or 
silk  is  placed  at  one  end  of  the  incision  including  the  terminal  part  of  the 
mucosa  within  its  grasp.  The  bowel  is  steadied  by  the  ends  of  the  purse- 
string suture  Avhich  are  not  tied  and  by  forceps  which  grasp  the  suture 
opposite  its  ends.  With  a  sharp-pointed  knife  a  small  puncture  is  made 
in  the  mucosa  contained  AAdthin  the  grasp  of  the  suture  (Fig.  533).  A 
soft  rubber  catheter  of  medium  or  large  size,  Avliich  has  one  or  two  ex- 
tra perforations  near  its  tip,  is  inserted  through  the  punctured  wound 
until  the  upper  perforation  in  the  catheter  is  at  least  an  inch  within  the 
boAvel.     The  pursestring  suture  is  then  tied  snugly  around  the  catheter  and 


594 


OPERATIVE    SURGERY 


a  curved  needle  is  threaded  into  one  end  of  the  suture  and  thrust  through 
the  catheter,  the  ends  of  the  suture  being  again  tied.  In  this  manner  the 
catheter  is  held  snugly  in  position  and  will  not  be  dislodged  for  several  daj^s 
(Fig.  534).  It  is  then  laid  on  the  bed  of  mucous  membrane  which  has  been 
prepared  for  it  and  one  or  two  rows  of  continuous  right-angle  sutures  of 
silk  or  linen  bury  the  catheter  effectively  (Fig.  535). 

The  catheter  may  be  brought  through  a  stab  wound.  If  this  is  done,  it  should 
have  been  clamped  about  its  middle  before  it  was  inserted  in  the  bowel  to 
prevent  fecal  material  flowing  through  it  and  contaminating  the  stab  wound. 
The  clamp  on  the  middle  of  the  catheter  is  removed  after  its  end  has  been 
brought  through  the  stab  wound.  If  the  operation  is  for  postoperative  ob- 
struction and  the  loop  of  bowel  is  delivered  into  the  wound  previously  made, 


Fig.  534. — A  catheter  is  inserted  in  the  puncture  and  the  pursestring  suture  is  tied  snugly.  One 
end  of  the  pursestring  suture  is  threaded  on  a  sharp  needle  and  fixes  the  catheter  in  position.  The  portion 
of  the   catheter   that   lies   on   the   incision   is  buried   with   a   right   angle   stitch. 


the  catheter  may  be  connected  with  a  larger  rubber  tube  which  conducts 
the  discharges  into  a  receptacle.  If  omentum  is  readily  accessible  it  may 
be  sutured  around  the  tube  but  this  is  not  necessary.  A  tube  sutured  in  the 
manner  described  with  linen  or  silk  will  remain  in  position  from  six  to  ten 
days.  Although  fastened  securely  by  the  pursestring  suture  it  practically  al- 
ways cuts  loose  within  ten  days,  so  if  it  is  desired  to  prolong  the  drainage 
from  the  enterostomy  the  catheter  must  be  either  fastened  to  the  skin  by 
a  suture,  or,  better  still,  by  adhesive  plaster  strips,  as  practiced  by  Long. 
In  any  event  it  should  be  anchored  to  the  dressing  so  that  there  may  not  be 
any  pulling  on  the  suture  through  traction  on  the  tube. 

Coffey  has  well  established  the  principle   of  preventing  back  pressure 


THE   INTESTINES 


595 


from  the  abdominal  viscera,  as  when  traiisphinliiig  a  ureter  in  the  bladder 
or  the  bile  duct  in  the  intestine,  by  making  an  incision  down  to  the  mucosa 
and  then  inserting  the  duct  or  the  ureter  at  one  end  of  the  incision  so  that 
it  is  buried  in  tlie  wall  of  the  viscus  and  only  separated  from  the  interior 
by  the  tliickness  of  the  mucosa  for  the  length  of  the  incision.  In  this 
way  distention  causes  the  mucosa  to  press  against  the  transplanted  duct 
and  to  protect  its  lumen  from  the  direct  effect  of  pressure  to  which  it 
would  otherAvise  be  subjected.  The  advantages  of  using  this  method  of 
enterostomy  are  that  it  does  not  materially  prolong  the  operation,  and 
when  the  patient  has  recovered  from  the  effects  of  the  obstruction  and  the 
catheter  is  withdrawn  there  is  practically  no  drainage  of  fecal  matter  through 
the  tract  left  by  the  catheter.  Sometimes  a  small  amount  of  fecal  drainage 
occurs  for  a  few  days,  but  usually  there  is  none.     This,  of  course,  is  a  great 


Fig.   535. — The   enterostomy   is   completed.      Usually   there   is   no   leakage   of   fecal   matter   when    the   catheter 
is  withdrawn,   due  to   the  valve  formation   of   the  mucosa. 


advantage  over  the  older  method  of  a  large  opening  w'ith  eversion  of  the 
mucosa  and  a  fecal  fistula  difficult  to  repair. 

The  fecal  matter  in  the  small  intestine  is  always  liquid  and  is  usually  liq- 
uid in  the  cecum  and  in  the  right  half  of  the  colon.  The  formation  of  gas  in  the 
bowel  is  one  of  the  most  distressing  features  of  obstruction  and  by  producing 
great  intraintestinal  pressure  undoubtedly  forces  into  the  lymphatics  or  the 
veins  of  the  intestines  toxic  products  that  might  not  otherwise  be  absorbed.  A 
medium  sized  rubber  catheter  will  give  ready  exit  to  the  gas  and  the  liquid 
fecal  contents  of  the  small  intestine,  and  a  somewhat  larger  catheter  would 
be  amply  sufficient  for  the  cecum  and  ascending  colon.  A  large  tube  can 
do  no  more  than  empty  the  bowel,  which  the  smaller  catheter  does.  The 
large  tube  produces  more  trauma,  may  be  followed  by  the  necessity  of  clos- 


596 


OPERATIVE    SURGERY 


ing  the  opening  by  a  later  operation,  and  also  may  encroach  too  greatly  upon 
the  lumen  of  the  bowel  after  the  obstruction  has  been  overcome. 

The  principle  of  AYitzel  is  essentially  different  from  that  of  Coffey.  If 
the  bowel  is  greatly  distended  and  it  seems  impossible  to  free  the  mucosa 
without  injuring  it,  a  tube  may  be  inserted  according  to  the  principle  of  Wit- 
zel.  Here  the  wall  of  the  bowel  is  punctured  to  admit  the  tube,  which  is 
fixed  in  position,  as  has  been  described.  Then  the  1)owel  wall  is  folded  over 
the  tube  and  sutured  (Fig.  536 j.  A  cross-section  will  show  that  this  chan- 
nel is  composed  of  all  the  histologic  layers  of  the  bowel  wall.  Conse- 
quently the  peritoneum,  which  lines  the  tunnel  and  readily  forms  a  lym- 
phatic exudate,  will  make  a  rigid  tube  of  the  tunnel  in  which  the  catheter  has 
been  laid,  so  that  after  the  catheter  has  been  withdrawn  leakage  of  fecal 
matter  is  much  more  likely  to  occur.  Besides,  there  is  more  encroach- 
ment upon  the  lumen  of  the  bowel  by  the  AVitzel  principle  which  folds  in  all 


Fig.  536. — Enterostomy  according  to  the  principle  of  \\'itze!  without  an  incision  to  the   mucosa. 

layers  of  the  bowel  Avail  than  by  an  operation  performed  on  the  principle  of 
Coffey  in  which  the  catheter  lies  on  the  mucosa  and  the  mucosa  forms  a  valve 
(Fig.  537-A  and  B).  There  is  but  little  exudate  from  the  mucosa  and  th'e 
peritoneum  does  not  enter  into  the  floor  of  the  tunnel  of  an  enterostomy 
performed  in  this  latter  manner,  so  but  little  lymphatic  exudate  is  thrown 
out  and  when  the  catheter  is  withdrawn  the  mucosa  is  mobilized  and  the  in- 
traintestinal  pressure  quickly  closes  the  tunnel. 

This  operation  is  done  not  only  in  obstruction  but  after  resection  of  the 
bowel,  as  in  strangulated  hernia,  when  the  oral  portion  of  the  intestine 
is  greatly  distended.  After  the  resection,  an  enterostomy,  as  just,  de- 
scribed, is  done  on  the  proximal  side  of  the  resection,  the  catheter  having 
been  previously  introduced  through  a  stab  wound  and  its  distal  end  clamped 
before  the  catheter  is  inserted  into  the  bowel.  This  avoids  infection  of  the 
wound.     An  enterostomy  in  such   cases  has  a  very  valuable  function.     It 


THE    INTESTINES 


597 


drains  off  tlie  contents  of  the  obstructed  bowel  and  lessens  the  pressure  on 
the  healing  intestinal  Avonnd  where  the  resection  was  done.  Peristalsis  is 
ahva.vs  interfered  Avitli  in  obstruction,  even  when  a  resection  has  been  care- 
fully performed.  Tlie  peristalsis  may  be  so  weak  that  it  cannot  take  ad- 
vantage of  the  removal  of  the  obstructing  or  gangrenous  loop  sufficiently 
to  propel  the  contents  of  the  dilated  bowel  through  this  newly  sutured 
area.  The  enterostomy  tube,  however,  gives  immediate  exit  to  the  gas  in 
its  neighborhood  and  offers  much  less  resistance  to  the  passage  of  intestinal 
contents  than  would  occur  if  the  fecal  matter  had  to  be  propelled  through 
its  normal  route.  Consequently,  weak  peristalsis  that  is  sufficient  to  emptj^ 
the  contents  of  the  bowel  through  a  soft  rubber  catheter  that  is  contained 
in  an  enterostomy  wound,  may  not  have  force  enough  to  overcome  the 
normal  physiologic  resistance  of  the  rest  of  the  intestinal  tract  even  though 
the  immediate  obstruction  has  been  removed. 


Fig.  537. — A,  a  cross  section  of  enterostom\',  using  the  principle  of  Coffey;  B,  a  cross  section  of 
enterostom}',  using  the  principle  of  Witzel;  C,  longitudinal  section  of  enterostomy,  using  the  Coffey 
principle. 

If  liquid  feces  does  not  flow  sufficiently  freely  through  the  enteros- 
tomy tube  an  ounce  or  more  of  Avarm  water  is  injected  through  the  catheter 
into  the  bowel.  This  will  prevent  the  closing  of  the  openings  in  the  catheter 
by  the  mucosa  of  the  bowel  or  will  cause  the  dislodging  of  any  large  particles 
of  fecal  matter  that  may  occasionally  obstruct  the  opening  in  the  catheter. 
This,  however,  should  not  be  done  as  a  regular  practice  for  it  may  stimulate 
the  loop  of  bowel  that  contains  the  enterostomy  tube  to  strong  peristal- 
tic contraction.  AYhen  peristalsis  has  become  normal,  which  usually  oc- 
curs within  a  week  or  ten  days,  and  one  or  more  bowel  movements  have 
been  secured  through  the  anus  by  enemas,  the  enterostomy  tube  can  be 
safely  removed. 


598  OPERATWE    SURGERY 

It  is  au  old  saying  that  obstructed  bowel  should  never  be  returned  to  the 
abdomen  until  it  has  been  thoroughly  emptied.  This  is  an  unwise  practice 
and  has  been  responsible  for  the  introduction  of  glass  or  metal  tubes  through 
an  opening  in  the  bowel  and  the  threading  of  almost  the  whole  length  of 
the  small  intestine  on  such  a  tube  in  order  to  empty  the  fecal  contents  as 
far  as  the  upper  jejunum.  This  practice  tends  to  disregard  the  physiology 
of  the  intestines,  and  particularly  the  physiology  that  occurs  after  obstruc- 
tion. It  is  well  known  that  even  the  opening  of  the  abdomen  under  a  gen- 
eral anesthetic  is  followed  by  temporary  paresis  of  the  bowels.  This  is 
probably  a  protective  phenomenon  which  is  intended  to  keep  the  bowel  quiet 
so  that  a  neighboring  loop  or  omentum  may  plaster  over  an  injured  portion 
of  the  intestine  and  prevent  infection.  It  also  provides  physiologic  rest 
for  repair.  At  any  rate,  the  phenomenon  is  commonly  observed  and  is 
more  pronounced  with  increased  handling  of  the  viscera.  If,  then,  the  whole 
length  of  the  small  intestines  is  forcibly  threaded  over  a  rigid  tube  it  can 
readily  be  imagined  that  the  normal  reaction  would  be  a  complete  abolition 
of  peristalsis  for  a  considerable  time.  This  paralysis  of  the  bowel  wall  will 
do  much  more  harm  in  permitting  the  rapid  accumulation  of  gas  and  fecal 
contents  than  the  immediate  emptying  by  such  mechanical  means  will  do 
good.  If  the  obstruction  has  reached  such  a  stage  that  peristalsis  is  com- 
pletely and  permanently  abolished  nothing  can  save  the  patient,  but  if  there 
is  still  preserved  a  weak  peristalsis  the  performance  of  an  enterostomy,  such 
as  has  been  described,  with  exposure  of  a  single  loop  of  bowel,  will  relieve  the 
immediate  obstruction  in  this  loop  and  will  tend  to  encourage  the  emptying 
of  other  proximal  loops  that  still  have  sufficient  peristalsis  to  expel  their 
contents  when  both  the  pathologic  and  physiologic  obstruction  has  been  over- 
come by  the  enterostomy.  But  if  the  whole  length  of  the  bowel  has  been 
forcibly  threaded  over  a  stiff  metal  or  glass  tube  the  manipulation  of  the  in- 
testine will  in  all  probability  completely  abolish  the  weak  effort  at  peris- 
talsis that  still  remains.  It  is  in  such  cases  that  an  enterostomy  with  a  rub- 
ber catheter  performed  above  the  point  of  obstruction  gives  the  maximum 
chances  for  recovery. 

Whether  the  diseased  loop  of  bowel  is  to  be  removed  at  the  same  time 
the  enterostomy  is  done  depends  upon  the  pathology  that  is  present.  If 
the  bowel  contains  a  tumor  that  has  caused  the  obstruction  the  enterostomy 
should  be  pei'formed  as  the  first  operation  and  resection  done  later,  after 
the  effects  of  the  obstruction  have  been  overcome.  If  gangrene  or  perfora- 
tion is  present  or  seriously  threatens  the  loop  of  diseased  bowel  should  be 
removed  and  an  enterostomy  done  on  the  proximal  side  of  the  diseased  loop 
according  to  the  technic  that  has  just  been  described.  If  there  is  a  tumor 
in  the  transverse  or  descending  colon  or  sigmoid  and  the  obstruction  occurs 
from  this  growth,  an  enterostomy  is  best  done  in  the  cecum.  The  tumor 
should  be  removed  at  a  subsequent  operation,  probably  ten  days  or  two 
weeks  later. 


THE   INTESTINES 


599 


An  enterostomy  according  to  the  techuic  described  should  not  be  done 
Avith  tiie  idea  of  giving-  complete  rest  to  the  bowel  distal  to  it.  If  there  are 
multiple  ulcerations  in  the  colon,  Avithout  obstruction,  and  the  purpose  of 
the  operation  is  to  rest  the  colon  by  diverting  the  fecal  matter,  but  little 
good  is  accomplished  by  an  enterostomy  that  will  not  divert  all  of  the  fecal  con- 


Fig.    538.— The   enterostomy   of   John    Young   Brown,    with   a    slight    modification    as    exnlainerl    in    tJi» 
text.      The   proximal    end    is   temporarily    sutured    till    the    distal    tube    is    fixed.      The   sutures    mav    then    h 
reversed  and  a  tube  inserted,   or  this  may  be   done  two   days   later. 

tents.  Here  the  operation  may  be  performed  either  on  the  right  side,  using 
the  terminal  ileum  according  to  the  method  of  John  Young  Brown,  or  on  the 
left  side  above  the  growth,  using  the  sigmoid.  The  bowel  is  completely 
divided  in  either  instance. 

In  the  operation  of  BroAvn  an  incision  is  made  in  the  right  iliac  fossa. 
It  may  be   a  muscle-splitting  incision  according  to  the  McBurney  technic. 


eoo 


OPERATIVE    SURGERY 


The  cecum  is  recognized  and  tlie  lower  ileum  is  pvdled  into  the  wound.  Brown 
originally  advised  section  of  the  ileum  close  to  the  cecum,  and  when  the  con- 
tinuity of  the  intestinal  current  was  reestablished  it  was  necessary  to  im- 
plant the  ileum  into  the  cecum  or  ascending  colon  by  an  end-to-side  opera- 
tion. In  this  way  the  action  of  the  ileocecal  valve  is  lost.  By  selecting  a 
point  for  division  of  the  ileum  about  eight  inches  from  the  ileocecal  valve, 
the  future  union  of  the  ileum  by  the  end-to-end  method  is  possible  and  the 
action  of  the  ileocecal  valve  is  preserved.  The  mesentery  is  first  split  for  about 
an  inch  from  the  bowel  wall.     The  bleeding  vessels  are  controlled  by  liga- 


^m 

A 

^M 

■Iftv.^ 

/ 

/  .. 

i: 

/ 

t 

^ 

^1 

-^' 

1 

tl 

]  -( el  e  'V^.       V  o  T  ^  a  i'-'v-i  G"                -^  o 

Fig    539. — Sigmoidostomy    according   to    the    method    of    Mixter.      Insert    A    shows    the    lines    of    incision    to 
secure  a  bridge  of  skin  beneath  the   sigmoid. 


tures  or  sutures  which  cover  the  raw  surfacesi  as  fully  as  possible  be- 
fore opening  the  ileum.  Intestinal  clamps  are  placed  on  the  bowel  near 
the  line  of  division  and  the  ileum  is  severed  with  scissors,  cutting  from  the 
mesenteric  border  outward.  In  this  way  the  chances  of  infection  of  the 
mesentery  and  -of  the  triangular  space  where  the  mesentery  separates  to  in- 
volve the  bowel  are  reduced  to  a  minimum.  In  the  lower  end  of  the  ileum 
a  large-sized  rubber  catheter  is  fastened  by  suturing  it  to  the  bowel.  The 
catheter  should  reach  through  the  ileocecal  valve  into  the  cecum.  A  purse- 
string  suture  inverts  the  edges  of  the  stump  of  the  ileum  around  the  catheter 
as  in  operations  on  the  gall  bladder  (Fig.  538).     This  tube  is  clamped.     It  is 


THE   INTESTINES 


601 


oiil.y  used  to  irrigate  the  colon  with  some  fluid  that  is  supposed  to  have  a 
therainnUie  value.  In  the  upper  end  of  the  howel  a  larger  tu])e,  preferably 
a  rectal  tu))e,  is  inserted  in  a  siniihir  manner  and  is  connected  to  a  receptacle. 
The  bowel  ends  are  attached  to  the  parietal  peritoneum  by  a  few  sutures 
and  the  wound  is  packed  lightly  Avith  iodoform  gauze.  The  tube  in  the  dis- 
tal end  of  the  bowel  is  readily  kept  in  position  almost  indefinitely  but  the 
sutures  around  the  proximal  tube  through  which  the  fecal  matter  runs  soon 
cut  out  and  leakage  occurs  at  this  point  Avithin  a  few  days.  During  this  time, 
hoAvever,  granulations  have  sprung  up  and  the  raAv  surface  of  the  abdominal 
Avound  has  acquired  some  protection  against  the  septic  products  of  the  boAvel 
contents.    An  advantage  that  Brown  mentions  for  this  operation  is  that  there 


t^  .  • : : 

^         . 

r  'v 

' 

/■  -■, 

'  ''■? 

p  \  p  ■f\     1 1  o  V  Tri  1  11  e„      L_o 

Fig.   540. — Sigmoidostomy  with  the  bridge   of  skin   sutured   in   position.     The   sigmoid   is   opened   and  a   tube 
inserted  for  immediate  relief  of  obstruction. 

is  less  odor  than  Avhen  an  enterostomy  is  made  in  the  large  bowel,  but  the 
great  advantage  is  that  it  completely  diverts  the  fecal  current  and  it  so  rests 
the  portion  of  the  intestinal  tract  distal  to  this  enterostomy  as  to  give  it  the 
best  possible  opportunity  for  recovery. 

In  inoperable  cancer  of  the  rectum  often  a  permanent  enterostomy  must 
be  done.  Here  the  sigmoid  offers  a  satisfactory  site  for  the  operation  and  the 
method  of  Mixter  gives  good  results.  An  incision  is  made  along  the  outer 
portion  of  the  left  rectus  muscle  and  is  so  fashioned  that  a  small  tongue  or 
flap  of  skin  and  subcutaneous  tissue  is  formed  from  the  middle  of  the  incis- 


602 


OPERATIVE   SURGERY 


ion  with  the  base  outward  (Fig.  539-A).  After  dissecting  up  this  flap  with 
the  skin  and  fascia  and  turning  it  outward,  the  fibers  of  the  rectus  muscle 
are  split,  the  peritoneum  is  divided  and  the  sigmoid  delivered  into  the  wound. 
All  the  excess  of  the  sigmoid  is  shoved  vip  into  the  abdomen  so  that  as  little 
of  the  bowel  is  left  below  the  eviscerated  loop  as  possible.  In  this  way  a 
reservoir  for  fecal  matter  is  established.  The  mesentery  of  the  sigmoid  is 
split  for  about  two  inches  at  right  angles  to  the  long  axis  of  the  bowel,  and 
the  rectus  muscle  and  peritoneum  are  sutured  together  through  this  opening 
in  the  mesosigmoid  (Fig.  539).  The  reflected  flap  of  skin  and  fascia  is 
brought  through  this  opening  and  is  sutured  in  its  original  position.  In 
this   manner   the   loop    of   sigmoid   that   has   been    delivered   rests   upon   the 


— i  '-«. 

k\^ 

^i 

/■  ^^ 

'C'--^. 

■"   --' 

~",,  -" 

"1- 

y"^  ^ 

'/ 

Fig.   541. — Several  days  after  the  first  stage  of  the  operation,   the  bowel   is   divided  or  a  section  is  removed, 

leaving  an  upper  and  a  lower  opening. 


flap  of  skin  and  fascia  which  has  been  sutured  under  it  (Fig.  540).  If  the 
need  is  urgent  an  enterostomy  can  be  done  with  a  rubber  catheter  as  has 
been  described,  but  if  the  obstruction  is  not  complete  or  if  a  temporary  en- 
terostomy is  done,  five  or  six  days  later  the  exposed  loop  of  sigmoid  is  com- 
pletely divided  and  the  bleeding  points  are  controlled  by  whipping  them 
over  with  a  needle  and  thread  (Fig.  541).  The  two  ends  retract  and  are 
sufficiently  wide  apart  to  make  a  complete  break  in  the  fecal  current.  At 
the  same  time  the  distal  end  of  the  sigmoid  can  be  utilized  for  irrigations 
to  clean  out  the  rectum. 


THE   INTESTINES  603 

INTESTINAL  RESECTION 

AVJu'u  resection  of  the  boAvel  is  indicated  the  technic  to  be  adopted 
varies  somewhat,  depending  upon  whether  the  large  or  the  small  bowel  is  in- 
volved, but  the  same  principles  that  underlie  this  operation  are  applicable 
wherever  resection  is  employed. 

The  type  of  suture  and  the  advantages  of  a  continuous  mattress  or  right 
angle  stitch  that  penetrates  all  coats  of  the  intestine  have  been  described. 
The  two  operations  usually  employed  for  uniting  the  bowel  after  resec- 
tion are  the  lateral  or  the  end-to-end,  Avith  an  occasional  end-to-side  anas- 
tomosis. 

As  elsewhere  in  surgery  the  object  of  an  operation  should  be  first  of 
all  to  remove  or  to  correct  the  pathology  and,  second,  to  restore  the  tissues 
as  nearly  as  possible  to  their  physiologic  normal.  Lateral  intestinal  anas- 
tomosis does  not  fulfill  this  latter  indication.  The  work  of  Cannon  and  Mur- 
phy^  has  shown  that  in  lateral  anastomosis  peristalsis  in  the  region  of  the 
anastomosis  is  practically  abolished  and  food  can  be  pushed  through  the 
anastomotic  opening  only  when  a  column  of  it  extends  into  a  proximal  (oral) 
loop  where  peristalsis  is  unimpaired,  because  severing  the  circular  muscular 
fibers  in  lateral  anastomosis  abolishes  peristalsis  and  the  blind  pouches  at 
the  ends  cannot  be  completely  emptied.  These  investigators  also  found  that 
in  end-to-end  union  there  is  not  the  slightest  stasis  of  intestinal  contents  at 
the  site  of  operation.  Many  patients  with  a  lateral  anastomosis  are  able 
to  overcome  the  handicap  of  an  unphysiologic  procedure  and  have  no  symp- 
toms from  lateral  anastomosis.  This,  however,  is  by  no  means  always  true, 
and  the  eases  reported  by  John  T.  Moore,"  of  Houston,  and  many  others, 
show  that  the  complications  following  lateral  anastomosis  may  be  extremely 
serious. 

It  seems  established  and  admitted  that  an  end-to-end  union  of  intestine 
is  a  more  physiologic  procedure  than  a  lateral  anastomosis  and  other  things 
being  equal  would  be  the  preferable  operation.  Because  lateral  anastomosis 
does  not  always  give  disagreeable  symptoms  its  use  has  been  continued.  If 
the  patient  did  not  die  it  was  assumed  that  he  had  sufficiently  recovered. 
Similarly,  it  may  be  claimed  that  a  perfectly  compensated  valvular  lesion 
of  the  heart  is  of  no  significance  because  it  gives  the  patient  no  inconvenience 
and  causes  no  symptoms,  for  nature  can  often  take  up  a  burden  that  has 
been  imposed  and  compensate  for  it  in  such  a  manner  that  the  patient  does 
not  suffer. 

The  argument  against  end-to-end  union  of  the  intestine  has  been  that  the 
suture  line  is  likely  to  leak  either  at  the  mesenteric  junction  with  the  bowel 
or  at  a  point  opposite  to  this  where  the  nutrition  is  poor.  P  have  attempted 
to  show  in  previous  communications  that  while  the  triangular  space  where 


"Cannon  and  Murphy:     Ann.   Surg.,  xliii,   519-520. 
'Tr.   Southern    Surg.  Assn..   xxxi,   pp.   152-153. 

^Ann.  Surg.,  xxxviii,  747;   Southern  Med.  Jour.,  viii,  p.  298;   Surgery  of  the  Blood  Vessels,   St.  lyouis. 
1915.  C.  V.  Mosby  Co..  p.  204, 


604  OPERATIVE   SURGERY 

the  mesentery  splits  to  envelop  the  boAvel  has  been  considered  responsible 
for  most  of  the  failures  of  end-to-eud  union  of  the  intestine,  and  "while  it 
has  been  assumed  that  because  this  space  is  devoid  of  peritoneum  union 
here  is  difficult  and  leakage  probable,  the  real  cause  for  failure  is  not  the 
absence  of  peritoneum  in  this  region.  AV.  J.  Mayo  has  repeatedly  stated 
that  peritoneum  is  only  needed  on  one  side  and  this  mesenteric  space  is 
usually  carefully  sutured  by  every  operator  before  the  operation  is  com- 
pleted. The  great  trouble  is  that  many  surgeons  who  have  had  disastrous 
experience  in  end-to-end  union  infect  this  triangular  area  Avhen  the  lumen 
of  the  bowel  is  opened  by  cutting  the  bowel  from  the  convex  border  toward 
the  mesentery  and  then  clamping  and  suturing  the  triangular  space  between 
its  layers.  Dividing  the  bowel  in  this  manner  necessarily  carries  the  con- 
tents of  the  bowel  into  this  triangular  space  because  the  blades  of  the 
scissors  that  cut  through  the  lumen  of  the  bowel  must  be  contaminated  with 
fecal  contents  and  smear  the  bacteria  from  the  lumen  of  the  bowel  into  this 
space.  When  the  operation  is  com^Dleted  this  region  is  carefully  sutured 
and  later  when  leakage  occurs  here,  it  has  been  assumed  that  the  leakage 
is  due  to  the  lack  of  peritoneal  covering.  If  we  were  to  dip  a  i^latinum  loop 
into  fecal  contents,  smear  it  into  an  incised  wound  on  the  hand,  and  then 
later  suture  the  wound  verj'  carefully,  we  would  not  be  surprised  when  the 
sutures  broke  down.  It  is  for  the  same  reason  that  leakage  occurs  at  the 
mesenteric  triangular  space  which  is  composed  largely  of  areolar  tissue  rich 
in  lymphatics  and  small  blood  vessels,  and  which  once  infected  can  hardly 
be  sterilized. 

The  question  of  infection  in  intestinal  wounds  is  closely  allied  to 
the  nutrition  of  the  wound.  If  the  infection  is  mild  and  in  a  region  such 
as  the  free  border  of  the  intestine  Avhere  there  is  no  areolar  tissue,  the  in- 
fection may  be  overcome  if  the  blood  supply  to  that  part  of  the  bowel  has 
not  been  impaired. 

To  avoid  infection  or  to  render  it  as  mild  as  possible  the  ends  of  the 
bowel  should  be  cleaned.  This  should  be  done  with  great  care,  using  gauze 
Avrung  out  of  antiseptic  solution,  and  making  an  effort  to  clean  the  mucosa 
of  the  intestine  as  Ave  Avould  disinfect  the  skin  before  making  an  incision 
into  it.  It  may  be  impossible  to  sterilize  the  mucosa  of  the  intestine  just  as 
it  is  impossible  to  sterilize  the  skin  by  any  knoAvn  method  that  does  not  de- 
stroy the  skin,  but  certainly  the  majority  of  the  bacteria  can  be  remoA'ed, 
and  then  the  needle  and  thread  Avill  not  carry  the  infection  as  they  do  if 
the  fecal  matter  is  simply  squeezed  out  and  no  further  effort  is  made  to  clean 
the  boAvel  end.  Leakage  opposite  the  m.esenteric  border  in  end-to-end  union 
of  the  colon  may  be  due  to  lack  of  cleaning  the  bowel  end  with  antiseptic 
solution,  so  preventing  infection  where  the  nutrition  is  Aveakest.  If  the 
end  of  the  bowel,  and  particularly  of  the  colon,  is  not  made  as  nearly  aseptic 
as  possible,  Avhen  the  thread  pierces  its  lumen  it  carries  bacteria  through 
the  whole  tissue.  This  may  account  for  the  poor  healing  and  the  late  infec- 
tion of  the  stitches  that  haA-e  sometimes  been  noted  after  resection   of  the 


THE   INTESTINES 


605 


colon.  If  liie  ciul  of  liic  l)()A\el  is  clean  fecal  matter  when  turned  on  after 
removing  tiie  intestinal  clamps  will  only  contaminate  that  jiortion  of  the  thread 
within  the  lumen  and  there  is  less  chance  of  infection  from  the  thread  that 
is  already  buried  in  the  tissues  of  the  bowel. 

The  chief  objections,  then,  that  have  been  urged  against  end-to-end  union 
are :  first,  infection  or  leakage  at  the  mesenteric  border  and,  second,  infection 
or  leakage  at  a  point  opposite  to  the  mesenteric  border.  The  cause  of  leak- 
age at  the  mesenteric  border  has  been  shown  to  be  soiling  of  this  region  by 
the  technic  of  cutting  the  bowel  from  the  convex  border  into  the  mesentery. 
Leakage  opposite  the  mesenteric  border  or  elsewhere,  when  the  sutures  have 
been  properlj^  placed,  is  probably  due  to  the  fact  that  the  ends  of  the  bowels 
have  not  been  thoroughly  cleaned  and  the  suture  drags  along  with  it  the 
bacteria  of  the  fecal  contents. 


Fig.  54J.  —  '1  Ik-  author's  mechod  of  intestinal  resection.  Before  the  bowel  is  divided,  the  mesentery- 
is  cut  close  tij  the  bowel  wall  and  the  triangular  space  caused  by  the  separation  of  the  layers  of  the 
mesentery  just  before  they  cover  the  bowel  is  clamped  and  tied.  The  rest  of  the  mesentery  is  then 
severed  and  tied,  and  moist  gauze  packed  under  the  loop  of  bowel.  The  bowel  is  divided  somewhat 
obliquely   from  its   mesentery  border   outward. 


In  an  effort  to  obviate  these  difficulties  a  technic  for  end-to-end  union 
of  the  bowel  has  been  developed  in  experimental  work  and  employed  clini- 
cally in  many  cases  with  great  satisfaction.  The  method  when  applied  to  the 
small  bowel  is  as  follows:  The  segment  of  bowel  to  be  removed  is  delivered 
into  the  wound  and  surrounded  by  moist  gauze.  An  intestinal  clamp  is 
placed  at  a  point  about  four  inches  from  the  intended  line  of  resection.  The 
contents  of  the  bowel  loop  are  stripped  out  as  far  as  possible  to  a  point  about 
four  inches  beyond  the  other  line  of  resection,  where  another  intestinal 
clamp  is  placed.  The  mesentery  is  then  doubly  clamped,  divided,  and  tied. 
The  triangular  space  where  the  mesentery  joins  the  bowel  is  clamped  with 
hemostats  and  tied  with  silk  or  linen  (Fig.  542).  The  rest  of  the  mesentery 
may  be  tied  with  catgut.     If  the  operation  is  not  for  removal  of  a  malignant 


606 


OPERATIVE   SURGERY 


tumor  the  mesentery  is  cut  rather  eh)se  to  the  bowel.  This  step  avoids 
any  possibility  of  injuring  vessels  that  may  carry  nutrition  to  the  healthy 
intestine.  If  there  is  a  suspicion  of  malignancy  the  mesentery  should  be  cut 
farther  aM'ay,  but  care  is  taken  to  preserve  as  many  of  the  blood  vessels  that 
supply  the  healthy  bowel  as  possible.  If  the  operation  is  for  gangrene,  and 
particularly  if  it  is  for  thrombosis  of  the  arteries,  great  care  must  be  taken 
to  make  a  sufficiently  wide  excision  to  secure  bowel  that  will  Ijleed  freely. 
Many  disasters  have  occurred  from  making  resections  too  close  to  the  ap- 
parent disease.  Aside  from  the  application  of  a  few  extra  sutures  to  the 
mesentery  there  is  no  more  difficulty  in  taking  out  six  feet  of  intestine  than 
six  inches,  and  while,  of  course,  the  relation  of  nutrition  to  the  length  of 
the  bowel  should  be  considered,  at  least  a  third  of  the  total  length  of  the 
small  bowel  can  be  removed  without   seriously  interfering   with  nutrition. 


l-ig. 


543. — The    margins    of    the    bowel    are    caught    with    clamps    and    the    intestinal    end    is    cleaned    with 

wet  gauze. 


It  is  highly  important,  then,  to  see  that  the  resection  is  made  at  a  point  where 
the  blood  supply  is  unimpaired. 

After  severing  and  ligating  the  mesentery  and  clamping  and  tying  the  tri- 
angular mesenteric  space,  a  quantity  of  moist  gauze  is  packed  under  the  loop  that 
is  to  be  removed,  but  which  up  to  this  time  has  not  been  opened.  The  loop 
is  collapsed  because  its  contents  have  been  emptied  before  placing  the  in- 
testinal clamps.  A  pedicle  forceps  is  placed  on  the  loop  of  the  bowel  as 
close  as  possible  to  the  line  of  resection.  The  bowel  is  divided  with  scis- 
sors, beginning  at  the  mesentery  at  the  point  where  the  triangular  space 
has  been  clamped  and  tied  and  going  upward,  slightly  inclining  toward 
the  healthy  bowel  so  it  will  not  be  deprived  of  its  blood  supply.  This  in- 
cision should  be  made  quickly  and  moist  gauze  should  at  once  be  placed 
over  the  end  of  the  diseased  loop.  Three  or  four  Allis  forceps  or  mos- 
quito forceps  grasp  the  margins  of  the  healthy  end  of  the  bowel  at  about 
equidistant  points.     The  end  of  the  bowel  as  far  as  the  intestinal  clamp  is 


THE   INTESTINES 


G07 


tliorouglily  cleaiu'd  willi  gauze  sponges  that  have  been  dipped  in  bichlorid 
solution,  while  the  forceps  that  have  been  placed  along  the  edge  of  the 
severed  bowel  hold  the  Inmen  open  (Fig.  543).  This  cleansing  should  be 
done  by  the  surgeon  Avhile  the  assistant  holds  the  forceps,  and  great  care  is 
taken  to  see  that  every  wet  sponge  that  is  used  to  clean  the  bowel  touches 
nothing  but  the  bowel  end  and  that  the  used  sponge  is  immediately  deposited 
in  some  basin  or  bucket  which  is  a  container  for  dirty  dressings.  AVhen  all 
the  fecal  matter  has  been  removed  by  gentle  sponging,  the  excess  of  bichlorid 
is  mopped  out  of  the  end,  and  it  is  covered  with  a  gauze  pad  wet  in  salt 
solution,  after  clamping  and  tying  with  catgut  any  bleeding  points  along 
the  cut  margin.  The  clamping  of  these  points  may  be  done  immediately 
when  the  bowel  is  cut,  but  they  should  not  be  tied  until  after  it  has  been 
cleaned.  Whi]3ping  the  bleeding  points  over  with  catgut  in  a  needle  is 
more  satisfactory  than  simple  ligation  which  in  their  region  often  loosens. 


Fig.  544. — The  first  stitch  begins  in  the  end  of  the  buwcl  on  the  operator's  right,  about  one-third 
of  an  inch  from  the  mesenteric  border,  and  is  tied  as  a  mattress  suture.  It  is  continued  along  the 
mesenteric  border  of  the  bowel  as  a  continuous  mattress  suture. 

The  other  end  of  the  loop  to  be  excised  is  severed  in  a  similar  manner  and 
the  other  end  of  the  healthy  bowel  is  similarly  cleaned. 

Suturing  is  begun  with  a  straight  needle  and  linen  thread,  inserting  the 
needle  from  the  mucous  membrane  of  the  right-hand  bowel  end  about  a  third 
of  an  inch  external  to  the  mesenteric  border.  The  needle  is  carried  to  the 
other  bowel  end  and  pierces  it  from  the  peritoneal  surface  toward  the  mucosa 
returning  in  an  opposite  direction.  It  is  then  carried  to  the  end  of  the  bowel 
from  which  the  suture  started  and  is  thrust  through  from  the  peritoneal 
surface  to  the  mucosa.  A  knot  is  tied,  which  makes  a  mattress  suture 
with  the  knot  on  the  mucous  membrane  (Fig.  544).  The  short  end  of  this 
thread  is  clamped  with  a  hemostat  and  the  suture  is  continued  by  carrying- 
it  back  and  forth  across  the  mesenteric  border  of  the  intestine  after  the 
manner  of  a  continuous  mattress  stitch.  It  should  grasp  a  portion  of  the 
ligated  triangular  mesenteric  space  on  each  side  to  prevent  the  possibility 


608 


OPERATIVE    SURGERY 


of  the  mesentery  retracting  at  this  point.  As  the  bowel  and  mesentery  are 
thicker  than  the  layers  of  the  bowel  elsewhere  it  is  essential  to  draw  these 
structures  more  snugly  together  th.in  in  the  other  portions  of  the  bowel. 
After  about  one-third  of  the  circumference  of  the  bowel  has  been  sutured  the 
needle  is  thrust  through  tlie  bowel  from  the  lumen  of  the  right-hand  end  (from 


Fig.  54S. — After  about  oue-tliird  of  the  ciixumference  has  been  sutured,  the  needle  is  thrust  through 
the  bowel  from  within  outward.  A  back  stitch  is  taken  and  the  suturing  is  continued  as  a  right  angle 
suture,  penetrating  all  coats. 


Fig.    S4t 


cnniiiuud    a-,   a   riulii    aiiule    Miiiiii.    turning  in   a   small   margin   of   the   bowel   and 
taking  a  back  stitcli  aljout  cverj-   third  or   fourth   suture. 


the  standpoint  of  the  surgeon),  which  is  the  end  containing  the  first  knot 
(Fig.  545).  After  emerging  by  being  thrust  through  from  the  lumen  to 
the  peritoneal  coat,  a  back  stitch  is  taken  by  merely  taking  two  stitches 
at  practically  the  same  point.  This  locks  the  roAV  of  sutures  that  has  been 
placed  so  far,  and  it  is  then  continued  as  a  right-angle  continuous  su- 
ture penetrating  all  coats  (Fig.  546).  The  suture  is  carried  about  a  sixth 
of  an  inch  from  the  incised  peritoneum  along  the  margin  of  the  intestinal 


THE   INTESTINES 


609 


wound.  If  more  tliau  tliis  aniouiit  of  lK)\vel  is  turned  hi  there  will  be  too 
luucli  diaj^liraiiin.  Only  enouiili  periloneuin  is  inverted  to  make  a  secure  ap- 
proximation. At  about  every  fourth  insertion  of  the  needle  a  back  stitch  is 
taken  by  taking  two  sutures  in  the  same  place,  or  the  last  stitch  just  behind 
the  preceding-  one.  This  prevents  the  thread  from  being  drawn  too  tightly 
and  so  diminishing  unduly  the  caliber  of  the  bowel.  The  bowel  is  approxi- 
mated just  snugly  enough  to  have  apposition  and  without  the  tension  used 
in  the  mesenteric  portion.  As  the  bowel  has  been  cut  somewhat  obliquely 
the  suturing  cannot  cause  too  much  diminution  of  the  lumen  unless  it  is 
drawn  too  tight  or  unless  too  great  a  diaphragm  is  turned  in.  The  evils 
of  these  two  errors  have  already  been  discussed  under  the  head  of  intes- 
tinal suturing.  The  suturing  is  continued  toward  the  operator  and  is  car- 
ried one  stitch  beyond  the  lowest  point  where  the  original  thread  was  left 
when  the  knot  was  tied  (Fig.  547).  This  last  stitch  is  on  the  left-hand  end 
of  the  bowel,  the  knot  being  in  the  other  end.  The  thread  is  then  firmly 
tied   to    the   end   that   was    caught   in   a    hemostat    at    the    beginning    of    the 


Fig.  547. — The  last  stitch  is  taken  in  the  left  end  of  the  bowel,  slightly  beyond  the  lowest  point 
where  the  original  end  of  the  thread  comes  out.  It  is  tied  snugly  to  the  original  end  three  or  four  times 
and  the  ends  are   cut   short. 


suturing.  The  knot  is  run  down  parallel  to  the  line  of  suturing  so  as  to  sink 
in  easily  and  is  tied  snugly  three  times.  It  is  then  cut  short  and  the  ends 
should  disappear  in  the  bowel  or  should  be  tucked  in  with  m,osquito  forceps. 
If  a  back  stitch  has  been  taken  at  proper  intervals  there  is  no  danger  of 
reducing  the  lumen  by  tying  this  knot  too  tightly,  but,  as  has  already  been 
pointed  out,  if  it  is  tied  too  tightly  it  may  cause  leakage  from  necrosis. 

When  the  suturing  is  begun,  the  gauze  that  has  been  laid  on  the  stumps  of 
the  mesentery  and  beneath  the  bowel  loop  to  be  resected  must  be  removed  in  order 
satisfactorily  to  approximate  the  ends  of  the  bowel  when  the  first  knot  is  tied.  If 
there  are  weak  points  along  the  suture  line  an  extra  interrupted  suture  may  be 
inserted,  but  this  should  be  avoided  by  careful  attention  to  the  sutures  as  they 
are  placed,  for  an  extra  stitch  turns  in  an  additional  amount  of  bowel,  makes 
a  broader  diaphragm,  and  places  an  extra  burden  upon  the  tissues  at  this 
point. 


610  OPERATIVE    SURGERY 

The  severed  mesentery  is  approximated  with  a  continuous  suture  of  plain 
or  tanned  catgut  in  a  round  needle,  taking  care  to  avoid  injury  to  any  blood 
vessel  and  securing  only  a  slight  hold  along  the  edges  of  the  incised  mesentery. 
The  bowel  is  sponged  with  salt  solution  and,  if  there  is  no  marked  distention 
on  the  proximal  side  of  the  resection,  the  intestine  may  be  returned  to  the 
abdominal  cavity  and  the  wound  closed  without  drainage.  If,  however,  there 
is  marked  distention  an  enterostomj'  should  be  done  two  inches  to  the  proxi- 
mal (oral)  side  of  the  resected  bowel  to  relieve  the  tension  on  the  sutures 
and  to  secure  an  early  and  easy  emptying  of  the  bowel  contents. 

If  the  cecum  and  ascending  colon  are  resected,  the  anatomic  and  the 
physiologic  conditions  are  somewhat  different  from  what  is  found  in  the 
small  bowel.  Here  it  is  necessary  to  unite  bowel  of  unequal  caliber  and 
of  different  gross  anatomical  structure.  It  is  also  desirable,  as  has  been 
pointed  out  by  Kellogg  and  others,  to  reproduce  a  valve  like  the  ileocecal 
valve  whenever  the  small  intestine  is  united  to  the  colon.  It  has  been  the 
common  experience  that  when  union  of  small  intestine  to  the  colon  is  made 
without  a  provision  of  this  kind  the  small  bowel  usually  dilates  or  thickens. 
This  is  probably  due  partly  to  infection  from  the  colon  and  partly  to  the 
back  pressure  of  gas  in  the  large  intestine.  While,  of  course,  such  a  valve 
cannot  prevent  the  entrance  of  a  small  amount  of  the  bacterial  flora  from  the 
colon,  it  may  act  as  an  ileocecal  valve  and  protect  the  small  bowel  from  an 
overwhelming  amount  of  colonic  fecal  matter  which  would  otherwise  flood 
the  ileum  with  each  retrograde  peristaltic  wave.  Resection  of  the  cecum 
and  ascending  colon  is  clone  by  a  modification  of  the  technic  used  for  re- 
secting the  small  bowel.  The  same  principles  of  avoiding  infection  of  the 
mesenteric  spaces  and  of  cleaning  the  bowel  ends  are  employed.  Even 
greater  care  should  be  taken  when  the  colon  is  involved  because  of  the  large 
amount  of  bacteria  always  present. 

The  first  step  is  a  thorough  mobilization  of  the  cecum,  ascending  colon, 
and  the  lower  part  of  the  ileum.  This  is  obtained  by  dividing  the  peri- 
toneum to  the  outer  side  of  the  mesentery  of  the  cecum  and  ascending  colon 
and  retracting  the  large  bowel  toward  the  midline.  The  .mesentery  which 
supplies  the  segment  to  be  removed  is  divided,  taking  as  much  as  possible 
of  it  in  malignancy,  but  being  careful  not  to  interfere  with  the  blood  sup- 
ply of  the  ends  of  the  bowel  that  are  to  be  united  after  resection.  The  transverse 
colon  may  be  clamped  after  making  an  opening  in  the  gastrocolic  omentum 
to  insert  one  blade  of  the  intestinal  clamp.  This  gives  a  sufficient  stump  of 
the  right  half  of  the  transverse  colon  to  permit  the  necessary  manipulations  dur- 
ing suturing.  After  severing  the  mesentery  and  securing  the  triangular  area, 
as  haf;  been  described  in  resection  of  the  small  bowel,  the  ileum  is  divided  first, 
because  this  end  is  probably  less  septic  than  the  colon.  The  severed  end  of  the 
loop  is  covered  with  moist  gauze  and  the  oral  end  of  the  ileum  is  cleaned.  The 
distal  end  of  the  loop  is  divided  by  first  clamping  the  colon,  protecting  thor- 
oughly the  tissues  in  the  neighborhood  with  moist  gauze,  and  then  severing  the 
bowel  from  the  mesenteric  border  outward.     The  edges  of  the  stump  of  the 


THE   INTESTINES 


611 


transverse  colon  are  caught  as  the  loop  is  severed  in  order  to  hold  up  the  stump 
of  the  bowel  and  prevent  leakage  of  its  contents.  This  end  is  thoroughly 
cleaned.  Suturing  is  l)egun  with  a  straight  needle  and  linen  thread  be- 
ginning on  the  mucosa  of  the  colon.  Tlie  needle  is  carried  through  the  colon 
to  the  ileum  and  pierces  the  ileum  about  an  inch  from  its  end.  The  needle 
pierces  the  ileum  from  without  inward  and  returns  in  a  reversed  direction 
through  vhe  iUuun  and  the  colon.  The  thread  is  tied  on  the  mucosa  of  the 
colon,  making  a  mattress  stitch.  The  short  end  of  the  thread  is  clamped  \v:th  a 
hemostat  (Fig.  548),  and  the  suture  is  continued  by  carrying  it  back  and 
forth  after  the  manner  of  a  continuous  mattress  stitch,  taking  more  of  the 
colon  Ihar.  of  the  ileum  in  each  bite  and  keeping  an  inch  behind  the  end  of  the 


Fig.  S4S. — The  author's  method  of  resection  of  eecum  and  ascending  colon.  The  bowel  ends  have 
been  cleaned  and  the  suturing  begins  from  the  mucosa  of  the  colon.  The  needle  pierces  the  colon  near 
Its  margin  from  within  out,  and  then  takes  a  bite  in  the  ileum  about  an  inch  from  its  end,  penetrating  to 
the  lumen  of  the  ileum.  It  then  returns  in  a  reversed  direction  to  the  lumen  of  the  colon  and  is  tied, 
making  a  mattress  stitch.  The  short  end  is  clamped.  The  next  stitch  is  taken  in  the  ileum  on  the  left 
side  as  close  to  its  mesentery  as  possible.  The  needle  is  then  carried  through  the  colon  and  the  next 
stitch  in  the  ileum  is  taken  close  to  the  right  side  of  the  mesentery  of  the  ileum.  In  this  way  the 
mesentery  is  brought  into  the  colon  without  too  much  compression  and  at  the  same  tiine  is  made  snug. 


ileum.  The  suture  is  so  inserted  that  at  the  mesenteric  junction  of  the  ileum 
the  suture  is  close  to  the  mesentery,  then  goes  to  the  colon  and,  returning,  takes 
another  bite  close  to  the  other  side  of  the  mesentery  of  the  ileum.  This  is  drawn 
snugly.  Inserting  the  suture  in  this  manner  avoids  cutting  off  the  nutrition 
that  may  be  carried  to  the  stump  of  the  ileum  and  at  the  same  time  makes  ap- 
position sufficiently  close  to  prevent  leakage.  After  the  mesenteric  border  has 
been  well  passed  the  stitch  is  brought  on  to  the  surface  by  thrusting  the  needle 
through  the  colon  from  within  its  lumen  and  continuing  the  stitch  as  a  right- 
angle  suture,  penetrating  all  coats.  It  unites  the  edge  of  the  colon  to  the  ileum 
about  an  inch  from  its  end,  while  taking  a  little  more  of  the  colon  than  the  ileum 
in  each  stitch,    A  back  stitch  is  made  about  every  third  or  fourth  bite  of  the 


612 


OPERATIVE    SURGERY 


needle  (Fig.  549).  AVhen  the  suture  has  reached  its  point  of  heginning  it  is 
carried  on  the  ileum  one  stitch  beyond  tlie  short  end  of  the  tliread  that  was 
left  clamped  and  is  tied  to  the  short  end.  The  knot  is  tied  snugly  three  times 
in  the  line  of  the  incision  and  is  cut  short. 

In  this  operation  there  is  not  the  danger  of  turning  in  too  much  dia- 
phragm, which  is  an  error  to  be  avoided  m  resection  of  the  small  intestine, 
and  it  is  best  to  place  a  row  of  interrupted  mattress  stitches  of  fine  tanned 
catgut  around  the  whole  line  of  sutures.  This  promotes  valve  formation  and 
adds  to  the  safety  of  the  line  of  sutures  which  has  an  unusual  amount  of 
strain  due  to  the  back  pressure  from  the  large  boAvel. 

An  enterostomy  is  ahvays  done  before  the  clamps  are  removed.  This 
should  be  performed  in  the  manner  already  described,  utilizing  the  principle 


Tig.  :-,^. — TL'^  suruiiiiig  i=  Loiuinuud  as  a  right  angle  continuous  stitch,  penetrating  all  coats  of 
the  intestine  and  uniting  the  edge  of  the  colon  to  the  ileum  about  an  inch  from  its  end.  More  of  the 
colon  than  of  the  ileum  is  taken  in  each  bite  and  at  about  every  third  or  fourth  stitch  a  back  stitch  is  takea. 
The  suture  is  completed  by  tying  it  to  the  original  short  end  that  was  left  clamped.  Insert  A  shows  a 
longitudinal  section  of  the  bowel  after  completion  of  the  first  row  of  sutures  and  the  insertion  of  the 
catgut  mattress   sutures. 

of  Coffey  but  instead  of  placing  the  enterostomy  in  the  colon,  as  I  originally 
advocated,  it  is  made  in  the  ileum  about  one  or  two  inches  above  the  line 
of  suturing.  A  medium  or  small  sized  soft  rubber  catheter  with  several 
perforations  near  its  end  is  used  and  should  l)e  brought  through  a  stab  wound 
in  the  abdominal  wall  to  the  outer  side  of  the  incision  and  the  distal  end 
clamped  before  tiie  catheter  is  placed  in  the  enterostomy  wound  (Fig.  550). 
The  end  of  the  catheter  should  go  through  the  lumen  of  the  sutured  bowel 
and  about  an  inch  of  it  should  rest  within  the  colon.  The  catheter  should 
not  be  large,  for  it  may  cause  obstruction,  and  a  small  catheter  will  give  suffi- 
cient exit  to  gas  and  liquid  feces,  which  is  all  that  is  necessary.  The  omentum 
in  the  neighborhood  is  brought  over  the  enterostomy  and  the  line  of  union 
of  the  bowel,  and  fastened  in  position  with  a  few  interrupted  sutures  of  fine 


THE   INTESTINES 


613 


tanned  cato'ut.  The  AV(nin(l  in  the  mesentery  is  closed  by  a  continuous  suture 
of  catiiut  and  the  inlesiin;il  clamps  are  removed. 

Abdominal  Avounds  after  resection  of  the  bowel,  and  particularly-  the 
large  bowel,  are  best  closed  with  interrupted  sutures  of  silkworm-gut  in 
ordtn-  to  avoid  the  unfortunate  consequences  that  might  follow  infection  of  the 
wound  if  catgut  sutui-es  were  used. 

The  advantages  of  enterostomy  after  resection  of  the  cecum  are  obvious. 
One  of  the  great  difficulties  after  this  operation  is  the  accumulation  of 
gas.  Some  surgeons  make  a  permanent  enterostomy  to  avoid  this.  Others 
make  an  end-to-side  union  and  bring  the  stump  of  the  colon  to  the  abdominal 
wall.  The  great  advantage  of  lessening  the  pressure  of  gas  on  the  suture  line 
during  the  healing  process  has  already  been  discussed.  This  is  obtained  by  an 
enterostomy,  such  as  has  been  described,  and  the  convalescence  proceeds 
without  distention  and  with  but  little  discomfort.     The  catheter  is  removed 


Fig.  550. — Longitudinal  section  of  the  completed  operation  with  the  enterostomy  tube  inserted 
through  the  ileum.  The  enterostomy  is  done  by  the  technic  previously  described.  The  tube  should  be  a 
medium  sized  or  small  catheter. 


in  a  week  or  ten  days  and  its  removal  is  usually  followed  by  no  leakage  of 
fecal  matter,  merely  a  drainage  of  purulent  serum  until  the  tract  closes. 

The  efficacy  of  the  valve  formation  is  shown  in  the  accompanying  roent- 
genogram, which  was  taken  after  an  enema  of  about  three  quarts  of  barium 
suspension  had  been  introduced  into  the  rectum.  The  picture  (Fig.  551)  was 
made  forty-one  days  after  resection  of  the  cecum  and  ascending  colon.  Al- 
though this  pressure  is  estimated  to  be  greater  than  the  normal  pressure  in 
the  colon  none  of  the  barium  reached  the  ileum.  There  has  been  no  symp- 
tom of  obstruction,  showing  that  the  union  at  the  site  of  resection  is  suffi- 
ciently patent.  This  method  of  operating  or  the  principles  underlying  the 
method,  such  as  the  treatment  of  the  mesentery  and  of  the  ends  of  the  bowel, 
and  end-to-end  union,  I  have  employed  in  ten  consecutive  cases  of  resection 
of  the  cecum  and  ascending  colon  without  a  death  and  without  any  compli- 
cation folloAving  the  operation. 

Eesection  of  any  other  portion  of  the  colon  down  to  the  lower  sigmoid 
can  be  done  bv  the  method  described  for  resection  of  the  small  bowel  except 


614 


OPERATIVE    SURGERY 


that  as  a  matter  of  precaution,  an  additional  layer  of  sutures,  preferably  in- 
terrupted mattress  sutures  of  fine  tanned  or  chromic  catgut,  is  placed  around 
the  boAvel  close  to  the  original  row.  Of  course,  there  is  no  occasion  for 
any  valve  formation  in  such  a  resection,  and  as  small  a  diaphragm  as  pos- 
sible should  be  turned  in.  As  the  fecal  matter  in  the  large  bowel  is  more 
nearly  solid  than  in  the  small  bowel  and  as  the  surfaces  of  the  colon  are  more 
irregular,  it  is  well  to  place  this  additional  row  of  sutures,  which  seems 
unnecessary  after  resection  of  the  small  bowel. 

There  is  a  marked  tendency  for  gas  formation  in  the  colon  and  if  the  re- 


Fig.  551. — A  roentgenogram  of  the  valve  made  after  resection  of  the  cecum  and  ascending  colon  by 
the  method  just  described.  The  roentgenogram  was  taken  forty-one  days  after  the  operation.  The  arrow 
shows  the  stump  of  the  colon.  Though  the  valve  was  subjected  to  the  pressure  of  three  quarts  of  barium 
enema,  it  seems   entirely   competent. 

section  is  on  the  left  side,  or  on  the  left  of  the  midline,  a  rectal  tube  or  a 
stomach  tube  should  be  passed  from  the  anus  well  through  the  site  of  re- 
section and  kept  in  position  for  four  or  five  days.  This  may  be  done  by  fas- 
tening the  tube  at  the  anus  either  by  a  suture  to  the  skin,  or  by  passing  a 
safety  pin  through  the  tube  and  letting  the  tube  at  this  point  emerge  through 
a  perforation  in  a  broad  strip  of  adhesive  placed  from  one  buttock  to 
another.  If  the  tube  is  not  stiff  it  may  double  up  in  the  rectum  and  it 
should  always  be  passed  through  the  point  of  resection  under  the  guidance  of 
the  hand  immediately  after  the  intestinal  clamps  have  been  removed.     If 


THE   INTESTINES 


615 


Fig.  552. — Lines  of  incision  for  excision  of  the 
bowel  and  mesentery  in  cancer  of  the  cecum  or 
ascending    colon. 


Fig.  553. — Lines  of  incision  for  excision  of  the 
bowel  and  mesentery  in  cancer  of  the  hepatic 
flexure  of  the  colon. 


Fig.  554. — Lines  of  incision  for  excision  of  the 
bowel  and  mesentery  in  cancer  of  the  splenic 
flexure  of  the  colon. 


Fig.  555. — Lines  of  incision  for  excision  of  the 
bowel  and  mesentery  in  cancer  of  the  descending 
colon. 


there  seems  to  be  doubt  about  the  tube  remaining  in  position  its  tip  may  be 
fixed  to  the  intestinal  wall  about  three  inches  to  the  oral  side  of  the  resec- 
tion by  transfixing  the  intestinal  wall  and  the  tube  with  a  catgut  suture. 
This  is  done  by  pressing  the  tip  of  the  tube  firmly  against  the  wall  and  passing 


616 


OPERATIVE    SURGERY 


the  sutiu-e  through  and  tying  it  in  several  knots.  The  suture  is  of  fine 
tanned  or  chromic  catgut  and  the  l^not  of  the  suture  is  buried  witli  a  purse- 
string  suture  of  silk  or  linen  Avliich  may  be  further  reinforced  by  bringing 
the  omentum  over  to  this  region.  Such  a  procedure  will  take  only  a  few 
minutes  and  if  the  surrounding  structures  are  Avell  protected  with  moist  gauze 
and  the  catgut  suture  is  regarded  as  a  septic  suture  and  immediately  buried, 
there  should  be  little  danger  of  infection.  Peristalsis  when  reestablished 
will  in  its  efforts  to  extrude  the  tube  readily  loosen  the  suture.  In  the  right 
side  of  the  transverse  colon  an  enterostomy  should  be  done  according  to  the 
method  indicated. 

Wherever  the  site  of  operation  on  the  colon,  great  stress  should  be  placed 
upon  the  first  step  of  thoroughly  mobilizing  the  colon  by  dividing  the  at- 


Fig.    556. — Lines    of    incision    for    excision    of    the 
bowel  and  mesentery  in  cancer  of  the  sigmoid. 


Fig.  557. — Lines  of  incision  for  excision  of  the 
bowel  and  mesentery  in  cancer  of  the  terminal 
sigmoid. 


tachments  of  the  peritoneum  on  its  outer  side  to  the  abdominal  wall.  In  this 
manner  the  descending  colon  which  is  difficult  of  access  can,  as  a  rule,  be 
readily  brought  into  the  wound.  It  must  also  be  borne  in  mind  that  in  opera- 
tions for  malignant  tumors  a  considerable  portion  of  the  apparently  healthy 
bowel  and  mesentery  must  be  excised.  The  illustrations  show  approximately 
the  amount  of  bowel  and  mesentery  that  should  be  removed  in  cancer  of  the 
colon  (Figs.  552,  553,  554,  555,  556  and  557). 

Cancer  in  the  terminal  portions  of  the  sigmoid  is  so  near  the  rectum  that 
a  part  of  the  rectum  must  be  removed  along  with  the  sigmoid.  The  operation 
here  involves  somewhat  different  principles  from  those  in  Avhieh  a  resection  is 
done  entirely  within  the  peritoneal  cavity  and  will  be  taken  up  along  with 
surgery  of  the  rectum. 


TJIK    INTKSTINES  617 

()l)s1nu'1i(m  of  llie  bowel  due  lo  cjiiumm-  ol'  llic  colon  iiiiist  be  managed 
sonu'wiiat  (lirfcmit  ly  from  olisl  nicl  ion  due  lo  liaiuls  or  strangulated  liernia. 
In  damaged  bowel,  snidi  as  a  sti'angnlaled  liernia  oi'  intussusception,  there 
is  great  danger  of  al)sor])tion  of  toxic  products  from  the  affected  loop.  These 
products  may  arise  Avithin  tlie  mucosa  and  result  from  a  perversion  of  the  nor- 
mal function  of  the  glantls  of  llie  mucosa,  or  tliej^  may  to  some  extent  be 
formed  within  the  lumen  of  the  boA\'el  and  can  more  readily  gain  access  to 
the  portal  circulation  through  the  damaged  bowel  than  through  normal  in- 
testine. Under  either  condition  the  necessity  of  immediately  resecting  the 
danuiged  loop  which  is  the  source  of  toxic  material  is  obvious.  This  may 
frequently  be  accompanied  b}^  an  enterostomy.  Obstruction  due  to  cancer 
of  the  colon,  however,  is  mechanical  and  death  results  from  the  damming 
back  of  the  fecal  current.  Such  an  obstruction  is  not  nearly  so  quickly 
fatal  as  is  an  obstruction  higher  up  in  the  intestinal  tract  or  when  a  loop  of 
bowel  has  been  damaged  by  strangulation,  volvulus  or  intussusception,  be- 
cause the  damaged  loop  generates  toxic  material  more  injurious  than  that 
which  results  solely  from  a  mechanical  damming  back  of  the  fecal  current. 
The  principles,  then,  of  treating  obstruction  due  to  cancer  of  the  colon  are ; 
first  of  all,  giving  exit  to  the  dammed  back  bowel  contents.  This  is  the  main 
indication  and  as  there  is  no  unusual  amount  of  toxic  material  being  gener- 
ated by  the  cancer  the  operation  for  removal  of  the  cancer  should  never  be 
done  at  the  time  the  obstruction  is  relieved  by  an  enterostomy.  The  method 
of  procedure  in  such  instances  is  first  to  Avash  out  the  stomach,  which  should 
be  the  first  step  in  the  treatment  of  every  intestinal  obstruction.  The  stomach 
should  be  thoroughl.y  cleaned  by  a  lavage  of  soda  w^ater  until  the  water  re- 
turns clear.  If  the  point  of  obstruction  can  be  determined  before  the  opera- 
tion so  much  the  better,  but  if  it  is  not  definitely  determined  it  would  be  wise 
to  make  an  incision  over  the  right  iliac  fossa  and  do  an  enterostomy  on  the 
cecum  if  it  is  apparent  that  the  obstruction  is  distal  to  the  cecum.  The  sutur- 
ing in  of  a  large  rubber  catheter,  utilizing  the  principle  of  Coffey  as  has 
already  been  discussed,  will  be  sufficient  to  relieve  the  obstruction  and  draw 
off  the  liquid  feces.  Fecal  matter  in  the  cecum  is  normally  liquid.  This  opera- 
tion can  usually  be  done  under  a  local  anesthetic,  which  adds  considerably  to 
the  margin  of  safety  in  operating  on  these  patients.  From  one  to  two  weeks 
later,  depending  upon  the  condition  of  the  patient,  the  exact  location  of  the 
growth  is  determined  by  a  barium  enema  injected  from  below,  together  with 
a  suspension  of  barium  injected  through  the  enterostomy  tube.  Two  days 
after  this  has  been  done  a  radical  operation  for  resection  of  the  growth  may 
be  performed.  The  technic  for  this  has  been  described.  If  the  cancer  is  so 
located  that  it  is  not  necessary  to  excise  the  cecum,  the  enterostomy  tube  is 
left  in  place  for  a  week  after  the  second  operation  and  is  then  withdrawn. 
This  procedure  may  be  carried  out  when  there  is  only  partial  obstruction, 
though  if  a  cancer  of  the  colon  can  be  diagnosed  when  there  is  no  obstruction,  it 
may  be  excised  at  one  operation. 

Formerly  excision  of  cancer  of  the  colon  at  one  sitting  was  considered  a 


618  OPERATIVE   SURGERY 

very  dangerous  operation  and  the  mortality  was  reduced  considerably  by  adopt- 
ing the  procedure  of  Mikulicz.  Here,  in  the  first  stage,  the  loop  of  bowel  con- 
taining the  growth  is  mobilized  and  brought  into  the  wound.  Its  limbs  are  su- 
tured to  each  other.  If  there  is  an  obstruction  an  enterostomy  may  be  done  on 
the  cecum  or  a  small  tube  is  inserted  in  the  loop  to  relieve  the  gas  and  liquid 
feces.  AVhether  there  is  obstruction  or  not,  the  loop  is  packed  around  with 
gauze  until  the  peritoneal  cavity  has  become  well  walled  off  and  after  a  week  is 
excised,  preferably  with  the  cautery.  This  results  in  an  artificial  anus.  A  few 
weeks  later  the  two  segments  of  colon  that  were  in  contact  and  were  sutured 
together  when  the  mobilized  loop  containing  the  cancer  was  first  delivered  into 
the  wound  are  opened  into  each  other  by  inserting  the  blade  of  a  pair  of  for- 
ceps in  one  of  the  open  bowel  ends  and  the  second  blade  in  the  other  end,  and 
then  clamping  the  forceps  so  as  to  produce  necrosis.  Later  still,  the  external 
opening  is  closed.  Though  this  method  resulted  in  the  reduction  of  operative 
mortality,  it  necessitated  a  rather  limited  resection  of  the  bowel  and  reciuired 
three  or  four  ditferent  operations.  During  intervals  between  these  operations 
the  wound  is  flooded  with  the  fecal  contents. 

Bevan'  has  called  attention  to  the  disadvantages  of  the  Mikulicz  method 
and  practices  a  right  iliac  enterostomy  with  later  a  resection  of  the  loop  con- 
taining the  cancer,  and  still  later  closure  of  the  enterostomy  opening.  This 
leaves  a  clean  field  for  the  resection. 

If,  however,  an  enterostomy  is  done  by  the  method  that  has  been  de- 
scribed and  through  a  muscle-splitting  incision  it  will  require  no  operation 
for  its  closure,  the  mere  withdrawal  of  the  tube  being  sufficient.  The  end- 
to-end  union  Avill  permit  a  resection  of  a  larger  amount  of  bowel  than  is  pos- 
sible with  a  lateral  anastomosis,  and  if  carried  out  according  to  the  technic 
described  has  other  advantages,  which  have  been  mentioned. 

In  operations  upon  the  rectum  and  terminal  sigmoid  where  the  fecal 
matter  is  largely  solid  an  enterostomy  by  insertion  of  a  large  rubber  catheter 
in  the  cecum  is  not  satisfactory.  Mixter's  operation  (pp.  600-602)  is  best  here 
and  should  always  be  used  in  inoi^erable  cancer  of  the  lower  sigmoid  and  rec- 
tum. A  permanent  anus  may  be  established  or,  if  it  is  thought  Avise  later 
on  to  restore  the  continuity  of  the  intestinal  tract,  this  can  be  done  by  anas- 
tomosing the  severed  ends  of  the  sigmoid.  A  restoration  of  the  fecal  current 
to  normal  should  not  be  attempted  for  a  number  of  weeks,  and  preferably 
several  months,  after  the  resection  of  the  rectum  or  lower  sigmoid.  Often 
when  the  patient  has  learned  to  care  for  the  colostomy  opening  he  is  much 
more  comfortable  with  a  permanent  colostomy  than  he  would  be  if  the  fecal  cur- 
rent were  restored  after  the  sphincteric  apparatus  of  the  lower  rectum  and  anus 
has  been  destroyed. 

A  diverticulum,  called  Meckel's  diverticulum,  is  sometimes  found.  It  is  an 
embrvologic  remnant  left  in  the  ileum  about  one  or  two  feet  from  the  ileoee- 


^Surgical  Clinics  of  Chicago,   February,   1920,   Philadelphia,   W.   B.   Saunders   Co.,  p.   9,   et   seq. 


THE   INTESTINES 


619 


cal  valve.  This  is  a  congenital  deformity  but  may  be  the  source  of  obstruc- 
tion or  of  adhesions  and  pain  (Fig.  558).  It  can  be  removed  by  first  clamp- 
ing the  loop  of  bowel  from  which  the  diverticulum  arises,  after  stripping 
it  of  fecal  matter,  and  then  surrounding  the  loop  with  moist  gauze.  The 
further  method  of  dealing  with  it  depends  upon  its  size  and  the  width  of  its 
base.  Frequentl.y  an  intestinal  clamp  can  be  adjusted  at  the  base  of  the 
diverticulum  which  is  then  severed  close  to  the  clamp,  leaving  a  sufficient  mar- 
gin of  tissue  for  suturing  so  the  lumen  of  the  bowel  will  not  be  narrowed  at 
this  point.  If,  as  often  happens,  a  mesentery  runs  along  the  diverticulum,  it 
is  separated  and  ligated  with  catgut.  It  is  then  divided  and  the  diverticulum  is 
clamped  close  to  the  intestine  and  cut  away.  The  small  margin  of  intestine 
included  in  the  rubber  covered  intestinal  clamp  placed  near  the  base  of  the 


Fig.   558. — Meckel's  diverticulum    in   the   lower  ileum. 


diverticulum  is  carefully  cleaned  by  sponges  wrung  out  of  bichloride  solu- 
tion and  the  edges  of  the  wound  are  approximated  with  a  fine  tanned  or 
chromic  catgut  lock  stitch.  This  is  done  not  only  to  approximate  the  mar- 
gins of  the  intestinal  wound  but  to  control  bleeding.  The  clamp  is  then  re- 
moved and  this  line  of  sutures  is  buried  by  a  continuous  right-angle  stitch 
of  linen  in  a  straight  needle,  taking  only  a  sufficient  amount  of  bowel  wall 
to  bury  the  first  line  of  sutures. 

Occasionally  it  is  necessary  to  do  a  lateral  anastomosis  in  order  to 
overcome  an  obstruction  in  the  bowel  which  it  is  not  practical  to  remove. 
This  may  be  permanent,  as  in  inoperable  cancer  of  the  splenic  colon  when 
a  lateral  anastomosis  may  be  made  between  the  transverse  colon  and  the 
sigmoid.  It  may,  however,  be  utilized  as  would  the  enterostomy  opera- 
tion in  order  to  overcome  obstruction  and  later  to  permit  a  radical  op- 
eration upon  the  cancer  or  stricture  v^^hich  causes  the  obstruction.      Some- 


620 


OPERATIVE    SURGERY 


times,  too,  an  anastomosis  between  tlie  cecum  and  tlie  si<>nioid  is  indicated. 
This,  of  course,  involves  the  same  principle  as  lateral  anastomosis  and  Avhen 
there  is  obstruction  along  the  colon  and  other  portions  of  the  intestine  cannot 
be  readily  approximated  Avithout  tension,  a  cecosigmoidostomy  will  offer  ex- 
cellent prospects  of  relief.  AVhen  performed  for  stasis,  however,  though  su- 
perior to  ileosigmoidostomy  it  is  stdl  very  unsatisfactory  so  far  as  clinical 
cure  or  improvement  of  the  patient  is  concerned. 

A  lateral  anastomosis  is  performed  in  much  the  same  way  as  a  gastro- 
enterostomy. The  intestinal  loops  to  be  anastomosed  are  selected  so  they  can 
be  easily  approximated  and  overlapped  without  the  slightest  tension.  Tension 
in  any  operation  of  this  type  is  fatal  to  success,  for  the  sutures  are  certain 
to  cut  loose  under  tension  and  in  cancer,  where  the  vitality  of  the   patient 


Fig.  559. — Lateral  anastiniuisis  .if  tin-  inti  ^tiius.  'i'lie  ends  of  the  bowel  are  closed  with  pursestriiig 
sutures  and  the  openings  are  made  close  to  the  invaginated  ends.  The  suturing  is  done  as  in  gastro- 
enterostomy. 

and  the  healing  of  tissues  is  at  a  low  ebb,  everything  possible  must  be  done 
to  promote  healing  of  the  intestinal  wound.  If  the  anastomosis  is  between 
loops  of  small  intestine  it  should  be  done  along  the  convex  border  opposite  the 
mesenteric  attachment.  If  the  lateral  anastomosis  is  to  be  between  loops  of 
the  large  intestine  it  is  preferably  done  through  the  anterior  band,  split- 
ting the  band  in  the  center,  as  this  makes  a  smoother  surface  though  it 
may  tend  late^  to  cause  a  contraction  of  the  anastomotic  opening.  After 
selecting  the  two  loops  of  bowel  and  arranging  for  thorough  mobilization  by 
incising  the  peritoneum  on  the  outer  side  of  the  mesocolon  if  necessary,  a  row  of 
fine  linen  or  silk  sutures  is  placed  just  on  the  margin  of  the  band,  if  the  colon 
is  being  united,  in  the  same  manner  as  the  jejunum  is  united  to  the  stomach 
in    gastroenterostomy.         These    sutures    are    placed    with    a    curved    needle 


THE   INTESTINES 


621 


and  arc  ri.<>lit-an<i'le  eontiiiuoiis  sutures,  taking  a  back  stitch  about  every  fourth 
insertion  ol'  the  needle.  After  this  row  has  been  placed,  another  back  stitch 
is  taken   aiul   the   needle   and  thread   are   Avrapped   in   gauze.     The   bowel   is 


Fig.   560. — I^ateral  anastomosis   between   the  jejunum   and   dilated   duodenum   for  obstruction  at  the  terminal 

duodenum. 


incised  about  the  middle  of  the  band,  the  edges  of  the  wound  are  caught 
with  mosquito  forceps,  and  the  mucosa  is  cleaned  with  moist  gauze  wrung 
out  of  bichloride  solution.    The  other  loop  is  incised  and  cleaned  in  a  similar 


622  OPERATIVE   SURGERY 

Avay.  The  edges  of  the  wound  are  united  by  a  No.  1  tanned  or  chromic 
catgut  suture  in  a  round  curved  needle,  beginning  at  the  end  of  the  incision 
where  the  first  row  of  sutures  terminated  (Fig.  559).  After  tying,  the  short 
end  is  clamped  with  a  hemostat  and  the  suture  is  carried  on  as  a  continuous 
lock  stitch,  snugly  applied  to  control  bleeding.  AYhen  the  other  end  of  the 
wound  is  reached  the  needle  is  thrust  through  from  the  mucosa  to  the  peri- 
toneal surface  and  the  suture  is  completed  as  a  right-angle  continuous  suture, 
penetrating  all  coats  and  taking  the  stitches  close  enough  together  to  control 
bleeding.  It  is  best  to  take  a  back  stitch  about  every  fourth  insertion  of  the 
needle.  Just  before  the  line  of  sutures  is  concluded  the  pressure  of  the  intes- 
tinal clamps  is  slightly  relaxed  by  gently  unlocking  the  handles  just  enough 
to  permit  a  return  of  the  circulation  and  to  demonstrate  whether  there  are 
bleeding  points.  This  should  be  done  very  carefully  first  on  one  side  and 
then  on  the  other,  because  if  the  clamps  are  loosened  too  much  the  wound 
may  be  flooded  with  fecal  matter.  There  is  not  so  much  danger  of  hemor- 
rhage here  as  in  gastroenterostomy.  After  demonstrating  whether  there  are 
l)leeding  points  the  pressure  of  the  clamps  is  reapplied  and  the  suture  is  con- 
cluded and  tied  three  or  four  times  to  the  original  end  that  was  left  clamped 
with  the  hemostat.  The  needle  and  thread  with  which  the  first  posterior 
row  of  sutures  was  applied  is  taken  up  and  continued  along  the  anterior  sur- 
face of  the  wound,  burying  the  catgut  row  and  placing  the  sutures  as  a 
right-angle  continuous  stitch,  which  terminates  at  the  point  of  its  begin- 
ning and  is  tied  to  the  original  end.  This  knot  is  buried  by  an  interrupted 
mattress  suture  and  another  is  placed  near  the  other  angle  of  the  wound 
in  order  to  take  the  strain  from  the  line  of  sutures  (Fig.  560).  The  great- 
est tension  naturally  Avill  be  at  the  two  ends,  just  as  one  rips  cloth  by  pulling 
it  apart  first  at  the  edge,  not  beginning  at  the  center ;  so  these  two  extremities  of 
a  line  of  sutures  should  always  be  protected.  After  cleaning  the  sutures  with 
moist  gauze,  the  bowel  is  returned  and  the  abdomen  is  closed  without  drainage. 
Practically  the  same  technic,  as  has  been  described,  is  used  in  cecosig- 
moidostomy,  except  that  the  union  cannot  always  be  made  between  the  bands 
of  the  cecum  and  the  sigmoid,  but  preferably  between  parts  on  which  there 
is  least  tension.  Some  operators  advocate  bringing  the  mesosigmoid  to  the 
mesentery  of  the  cecum  in  order  to  prevent  obstruction.  This  does  not  seem 
necessary  because  if  an  effort  is  made  to  join  these  two  mesenteries  there 
is  much  more  likelihood  of  an  obstruction  from  the  slipping  of  a  loop  of 
small  intestine  through  a  small  opening  between  them  that  may  not  be 
completely  closed  than  there  would  be  if  no  effort  was  made  to  approximate 
them.  The  cecum  should  never  be  anastomosed  to  the  sigmoid  unless  both 
of  these  portions  of  the  bowel  are  so  mobilized  that  there  will  be  not  the 
slightest  tension  on  the  line  of  sutures. 


CHAPTER  XXVII 

OPERATIONS  ON  THE  APPENDIX,  PERICOLONIC  BANDS,  THE 
LOWER  SIGMOID,  THE  RECTUM,  AND   THE  ANUS 

APPENDICITIS 

There  are  almost  as  many  methods  of  performing  appendectomy  as  there 
are  technics  for  the  correction  of  retroversion  of  the  uterus.  As  usual, 
however,  the  simplest  method  that  is  efficient  should  be  one  to  be  adopted. 
The  ]\IcBurney  incision  is  very  satisfactory,  especially  in  acute  appendi- 
citis. As  this  incision  is  often  used  it  is  illustrated  in  some  detail  (Figs. 
561,  562,  563,  564,  565,  566,  567  and  568).  In  my  experience  I  have  tried 
the  different  methods  of  treating  the  stump  of  the  appendix,  but  for  the 
last  twelve  years  I  have  practiced  two  procedures  that  have  given  the  utmost 
satisfaction.  In  the  majority  of  cases  the  appendiceal  stump  is  treated  sim- 
ply without  being  buried,  according  to  the  general  technic  employed  by 
the  early  operators  for  appendicitis.  If  this  is  impossible  because  of  the 
diseased  condition  of  its  base,  the  appendix  is  excised  flush  with  the  ce- 
cum and  the  cecal  wound  treated  as  though  it  were  a  stab  wound,  using 
either  a  single  pursestring  suture  after  controlling  the  bleeding,  or  else 
suturing  the  margins  of  the  wound  with  a  continuous  suture  of  tanned 
or  chromic  catgut  and  burying  this  with  a  second  row  of  right  angle  sutures 
of  linen  or  silk.  In  suturing  wounds  of  the  intestine,  if  the  bleeding  is  readily 
controlled,  one  row  of  sutures  is  all  that  is  necessary.  If,  however,  there  is 
doubt  about  controlling  the  bleeding,  as  where  the  bowel  is  clamped  in  such 
a  manner  as  to  cut  off  the  circulation,  or  in  the  larger  bowel,  where  the 
surface  is  irregular  and  the  intraintestinal  pressure  is  considerable,  two  rows 
of  sutures  should  be  employed.  As  wounds  of  the  cecum  belong  to  this  latter 
class  two  rows  of  sutures  after  complete  excision  of  the  appendix  are  advis- 
able. Such  indications,  however,  do  not  often  arise,  for  usually  a  sufficient 
amount  of  the  appendix  can  be  left  to  heal  as  a  stump.  The  technic  for 
appendectomy  that  I  have  found  satisfactory  for  either  chronic  appendi- 
citis or  the  great  majority-  of  cases  of  acute  appendicitis  is  as  follows: 

The  appendix  is,  if  possible,  delivered  into  the  wound.  It  is  clamped 
about  a  third  of  an  inch  from  its  base  and  two  catgut  ligatures  of  No.  1 
tanned  or  chromic  catgut  are  carried  through  the  mesoappendix  close  to 
the  base  of  the  appendix.  The  base  is  tied  flush  with  the  cecum  with  one 
of  the  ligatures,  tying  three  knots  and  clamping  the  long  ends.  The  mesen- 
tery of  the  appendix  is  tied  with  the  other  ligature  (Fig.  569).  If  the  mesen- 
tery is  fat  the  proposed  site  of  ligation  is  first  clamped  w^ith  a  pedicle 
forceps.    In  fat  patients  the  mesoappendix  sometimes  tears  and  retracts  when 

623 


624 


OPERATIVE   SURGERY 


clamped.  The  elam])iiiii'  sliould  not  be  loo  near  the  root  of  the  mesentery  so 
tlie  fat  retracted  mesoappendix  can  be  readily  caught  if  such  an  accident 
occurs.  AVhen  there  is  but  little  fat  there  is  no  occasion  for  clamping.  After 
tying  the  mesoappendix  it  is  severed  with  scissors,  leaving  a  sufficient  margin 


Fig.   561. — The   skin   incisiun    lor    the    MelJuriicy    inuscle    splitting   operation. 


Fig.  S62.--The  aponeurosis  of  the  external  oblique  is  split  in  the  direction  of  its  fibers. 

beyond  the  ligature  to  prevent  it  from  slipping.  The  ends  of  this  ligature  are 
tied  snugly  around  the  base  of  the  appendix  over  the  first  ligature  and  are  cut 
short.  This  prevents  retraction  of  the  stump  of  the  mesoappendix  which  some- 
times occurs  and  which  may  result  in  the  tearing  of  small  veins  with  disagree- 
able oozing.    The  base  of  the  appendix  is  surrounded  with  moist  gauze  and  is 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


625 


severed  willi  nn  clccl  ric  or  lliermo  cautery  close  to  the  cliiini)  miuI  about  a  fourth 
of  an  iiu'li  beyond  1  he  liizalnre  (Fig'.  570).  A  dry  sponge  is  ])biced  by  the 
stump  of  the  appendix  and  Ihe  eseluir  left  by  the  cautery  together  with  most 


Fig.  563. — The  aponeurosis  of  the  external  oblique  has  been  split  and  drawn  apart  with  retractors. 
The  fibers  of  the  internal  oblique  and  transversalis,  which  are  nearly  parallel  in  this  location,  are  separated 
by  inserting  closed  scissors  and  opening  their  blades. 


Fig.    564. — The   fibers   of   the   internal    oblique   and   transversalis   are    held    apart   with    retractors.      The   peri- 
toneum is  shown  in  the  wound. 

of  the  mucosa  of  the  stump  is  curetted  away  on  to  the  gauze  sponge  with  a 
small  sharp  curet  (Fig.  571).     The  point  of  a  scalpel  will  also  serve  for  this. 


626 


OPERATIVE    SURGERY 


A  drop  of  pure  carbolic  on  the  end  of  a  projjc  is  rubbed  into  the  stump  of 
the  appendix  and  the  gauze  sponge  on  to  which  the  eschar  and  mucosa  Avere 
curetted  is  removed.     The  excess  of  carbolic  is  removed  with  a  dry  gauze 


Fig.  565. — The  peritoneum  is  closed  with  pursestring  suture  or  a  continuous  mattress  suture  which 
everts  the  edges  of  the  cut  peritoneum  and  brings  broad  peritoneal  surfaces  in  contact.  The  insert  shows 
the  suture  in   the  peritoneum   after   it  has  been  tied. 


ig.    566.     The    fibers   of   the   internal    oblique   and    transversalis   muscles    are    approximated    by    a    suture    of 

plain  catgut  which  is  loosely   tied. 


sponge  and  the  ends  of  the  ligature  are  cut  about  a  fourth  of  an  inch 
from  the  knot.  The  wound  is  made  and  closed  as  described  in  the  chapter  on 
abdominal  incisions  and  as  shown  in  Fias.  5fi1  and  568. 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


627 


"Where  the  appendix  cannot  be  delivered  into  the  wound  the  technic  is 
altered  to  suit  the  oceasion.     The  appendix  is  first  ligated,  clamped  and  sev- 


Fig.    567. — The   aponeurosis   of    the    external    oblique   is   brought    together    with    a    continuous    lock    stitch    of 

plain  catgut. 


Fig.   568. — The  skin  is  closed  with  a  subcuticular  suture  of  fine  tanned   catgut. 


ered  at  its  base,  treating  the  stump  as  has  been  described  and  also  disin- 
fecting the  end  that  is  clamped  in  the  forceps.  The  mesoappendix  is  then 
clamped  from  the  base  outward  by  a  series  of  forceps  and  is  severed  as  each 


628 


OPERATIVE   SURGERY 


forceps  is  applied.    The  vessels  in  the  mesentery  are  controlled  by  sutures  of 
catgut.    In  some  difficult  cases  the  technic  originally  suggested  by  S.  J.  Mix- 

ter  is  valua1)le.     Here  the  appendix  is  severed  ;iiid  if  it  is  difficult  to  clamp 


Fig.    569. — The   appendix   and   its   mesentery   are   tied   with   tanned    catgut. 


Fig.    570. — The    appendix    is    severed   with    an    elirciric    cautery. 

the  mesoappendix  on  account  of  extensive  adhesions  and  if  the  appendix 
is  not  too  acutely  inflamed,  an  incision  is  made  around  it  close  to  the 
clamp,  going  only  through  the  peritoneal  and  muscular  coats  and  down 
to,  but  not  through,  the  mucosa.     This  incision  is  very  important  and  must 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


629 


be  carefully  made.  Tlir  iiuRMisa  should  he  slri])ped  out  T)}^  gently  push- 
ing down  1he  euCt'  of  the  peritoneal  and  muscular  coats  and  grasping  the 
mucosa  \\ith  forceps  as  it  is  being  delivered  from  its  attachment  to  the 
muscular  coat.  The  stripping  is  done  with  dry  gauze  on  sponge  holders 
or  pedicle  forceps  but  must  be  done  carefully,  for  if  the  mucosa  tears  the  wound 
may  be  infected  and  the  distal  part  of  the  appendix  is  then  delivered  with  consid- 
erable difficulty.  For  this  reason  if  there  is  much  inflammation  and  the  coats  of 
the  appendix  have  become  infiltrated  and  weakened,  the  mucosa  is  likely  to  tear 
and  this  procedure  should  not  be  attempted.  After  the  mucosa  of  the  appen- 
dix has  been  delivered  in  this  manner,  the  mouth  of  the  shell  from  which  it 
was  extracted,  which  consists  of  the  muscular  and  peritoneal  coats,  is  clamped 
and  tied  to  prevent  bleeding.  This  shell  fills  with  a  blood  clot  and  presents 
an  exact  cast  of  the  appendix.    If  the  mucosa  has  not  been  injured  the  blood 


Fig.   571. — The  eschar  and  the  mucosa  in  the  stump  are   curetted. 

clot  is  readily  absorbed.  A  complete  peritoneal  covering  is  left  where  other- 
wise would  be  an  extensive  raw  surface  Avhich  would  result  from  the  com- 
plete delivery  of  an  appendix  in  such  a  difficult  position.  This  procedure  is 
particularly  valuable  when  a  long  adherent  appendix  points  toward  the  liver. 
The  difference  in  results  of  an  operation  in  which  the  stump  of  the 
appendix  has  been  treated  as  described  and  in  which  it  has  been  buried 
is  well  shown  by  the  accompanying  cuts  (Figs.  572,  573,  574  and  575). 
A  false  analogy  is  often  responsible  for  burying  the  stump  of  the  appendix. 
It  has  been  assumed  that  there  should  be  no  raw  surface  left  in  the  peri- 
toneal cavity  whenever  it  can  be  prevented.  This,  as  a  rule,  is  a  good  doc- 
trine, but  there  are  exceptions.  Because  the  stump  of  a  broad  ligament  or 
of  an  amputated  uterus  is  buried  it  has  been  supposed  that  the  stump  of 
the  appendix  should  be  likcAvise  treated.  After  salpingectomy  or  a  hysterec- 
tomy the  ligated  pedicle  or  sutured  surface  is  turned  into  well  vascularized 


630 


OPERATIVE    SURGERY 


tissue  and  can  easily  be  absorbed  or  vascularized.  The  stump  of  a  ligated 
appendix,  however,  is  buried,  not  into  solid  well  vascularized  tissue,  but  into 
the   cavity  of  the   cecum   (Fig.   573).     The   nutrition   to   injured   tissue   de- 


Fig.    572. — The   stump   of   the  appendix   is   tied   and   a  pursestring   suture   for    invagination    of   the   stump   is 

placed. 


■  Fig.  573. — A  sectional  view  shows  the  result  of  the  invaginating  method.  The  blood  supply  is 
partly  cut  off  by  the  pursestring  suture,  a  piece  of  necrotic  stump  is  left  in  the  closed  cavity,  and  the 
mass  of  invaginated  tissue  can  be  almost  surrounded  by  fecal  contents.  It  is  impossible  for  the  omentum 
or  mesentery  to  reach  the  stump  of  the  appendix  and  a  prominent  lump  is  left  in  the  wall  of  the  cecum 
which  may  be  a  future  source  of  ulcer  or  of  cancer. 

pends,  among  other  things,  partly  upon  the  amount  of  damage  to  be  re- 
paired and  partly  upon  the  ease  with  which  the  blood  circulation  can  ap- 
proach the  site  of  injury.    In  the  simple  treatment  of  the  stump,  the  repair  of 


APPKXDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


631 


the  base  of  tlu'  .-ippcndix  (lush  with  the  colon  is  unobstructed.  Not  even  a 
clamp  that  crushes  liu'  mucosa  has  been  placed  here  and  so  the  blood  supply 
comes  to  the  lig'ated  base  without  hindrance.    The  stump  of  the  appendix  which 


Fig.    574. — The    simple    metliod    of    treating   the    stump    «i    tlic    appendix.      The    appendix    has    been    ligated 

and  the   stump   disinfected. 


Fig.  575. — A  sectional  view  showing  the  simple  method  of  treating  the  stump  of  the  appendix.     The  interior 
of   the   cecum   is   undisturbed   and   is   left   perfectly   smooth. 


is  ligated  is,  of  course,  necrotic  material.  It  has  probably  been  rendered  aseptic 
hy  severing  it  with  a  cautery,  curetting  and  disinfecting  with  carbolic.  This 
necrotic  material  to  be  successfully  disposed  of  must  be  removed  by  phagocytes. 


632 


OPERATIVE    SURGERY 


In  the  simple  treatment  of  the  stnmp  these  phagocytes  can  approach, 
not  only  through  the  unobstructed  lymph  and  blood  circulation  of  the  ce- 
cum to   the   base   of  the   appendix,   but   can   also   reach   the   stump   by   the 


Fig    576. 


-Reproduction    of    illustralion    by    Bunts,    showing    diverticulum    following    burying    the    stump    of 

the   appendix. 


Fig.   577. — Drawing  of  a  diverticulum   that  we   have   seen  following  burying  the  stump   of  the  appendi.K. 

omentum,  which  may  plaster  over  the  stump,  or  through  the  mesentery  of 
adjoining  loops  of  bowel.  In  this  way  even  an  infection  of  the  stump  may 
be  overcome  by  the  vigorous  and  obstructed  attack  of  the  leucocytes  (Figs. 
574  and  575).  After  the  stump  is  digested  and  removed  the  adherent  omen- 
tum or  mesentery  drops  away  and  leaves  a  smooth  cecal  wall  which  presents 


APPENDIX,    PERICOLIC    HANDS,    RECTUM,    ETC. 


633 


merely  a  sliglit  scaiTing-.  I  liave  had  occasion  to  operate  for  other  causes, 
on  a  numl)or  of  patients  in  whom  the  stump  of  the  appendix  has  been  treated 
in  this  simple  manner  and  in  no  instance  have  I  found  a  serious  adhesion  or 
other  complication.  In  the  majority  of  cases  in  which  the  stump  has  been 
buried  I  have  found  either  unusual  adhesions  or  a  lump  in  the  bowel  or  else 
a  diverticulum,  such  as  has  been  described  by  Bunts  and  which  he  has  well 

illustrated. 

If  we  were  to  establish  ideal  conditions  for  the  formation  of  an  abscess 
we  would  probably  prescribe;  first,  the  diminution  of  the  blood  supply  to 
the  tissues  in  which  the  abscess  is  to  be  located;  second,  the  presence  of  ne- 


Fig.  578. — A  small  rounded  residue  often  seen  at  the  site  of  the  appendix  stump  following  ap- 
pendectomy; also  sometimes  seen  about  the  base  of  a  diseased  appendix  before  removal.^  ''In  some  cases 
showing  such  a  residue  after  barium  meal,  the  operation  had  been  performed  years  before."  The  illustration 
was  kindly  sent  me  by  Dr.  James  T.  Case.  He  says  that  he  believes  that  this  residue  has  some  relation 
to  the  pursestring  suture  by  which  the  stump  is  buried.  Jour.  Am.  Med.  Assn.,  Nov.  6,  1915,  Ixv,  pp.  1628- 
1634.  ^      .,   ■     !.     ;    :.    I    U  .1^.. 


erotic  material ;  and  third,  the  formation  of  a  closed  sac.  These  conditions  are 
filled  when  the  stump  of  the  appendix  is  buried,  for  the  pursestring  suture 
not  only  forms  a  closed  sac  in  which  the  necrotic  stump  is  enclosed  but  it 
cuts  off  some  of  the  blood  supply  that  must  reach  the  base  of  the  stump  to 
produce  repair,  and  thereby  calls  for  a  much  greater  hyperemia  of  the  cecum 
than  would  otherwise  be  necessary.  This  excessive  hyperemia  often  means 
lymphatic  deposits  and  permanent  adhesions,  whereas  if  the  stump  is  treated 
simply  no  extra  burden  is  placed  upon  the  tissues  and  there  does  not  exist 
the  necessity  for  additional  hyperemia.     Then,  too,  the  neighboring  mesentery 


634  OPERATIVE    SURGERY 

and  omentum  aid  in  taking  care  of  the  necrotic  stump  ^vhen  it  is  not  buried. 
In  addition  to  forming  a  cavity  that  contains  necrotic  material  and  cutting  off 
the  nutrition  to  this  cavity  the  wall  of  the  cecum  within  the  grasp  of  the 
pursestring  .suture  is  inverted  into  the  liunen  of  the  cecum,  which  is  one  of 
the  most  septic  portions  of  the  intestinal  tract.  This  inversion  produces  also 
a  beginning  intussusception  and  a  protuberance  on  the  mucosa  of  the  cecum 
which  may  possibly  be  a  starting  point  for  ulceration  or  for  cancer. 

The  diverticulum  that  occasionally  forms  after  burying  the  stump  is 
thought  by  Bunts^  to  be  due  to  destruction  of  the  circular  fibers  around  the 
base  of  the  appendix  by  the  pursestring  suture  (Figs.  576  and  577).  Case- 
has  also  shown  by  roentgenograms  that  there  may  be  a  stasis  at  the  base  of 
the  appendix  where  a  pursestring  suture  has  been  used  even  years  after  the 
operation  has  been  performed  (Fig.  578 j. 

The  two  chief  objections  to  the  simple  method  of  treating  the  stump  of 
the  appendix  are;  first,  that  it  does  not  "look  good";  and,  second,  that  the 
ligature  on  the  stump  of  the  appendix  may  blow  off.  The  answer  to  the 
first  of  these  objections  is  obvious.  Surgical  operations  should  be  finished 
in  a  neat  and  workman-like  manner  if  possible,  but  more  important  still,  they 
should  be  based  upon  the  anatomy,  physiology,  and  pathology  of  the  tissues 
involved.  It  would  probably  look  well,  for  instance,  to  close  a  hernial  wound 
by  a  careful  subcuticular  suture  in  the  skin  without  the  proper  approxima- 
tion of  the  deep  structures,  but  no  one  would  consider  this  good  surgery.  As 
to  the  ligature  blowing  off,  this  is  much  less  likely  to  happen  on  the  stump 
of  an  appendix  than  on  a  blood  vessel.  The  stump  of  the  appendix  is  soft  and 
succulent  tissue  and  the  ligature  .sinks  in  well.  The  intracecal  pressure  never 
even  approximates  the  blood  pressure,  so  if  any  surgeon  is  capable  of  ligating 
a  large  blood  vessel,  he  should  .surely  be  able  successfully  to  tie  the  stump 
of  the  appendix.  If,  for  instance,  in  an  amputation  of  the  thigh  he  applied 
a  ligature  to  the  femoral  artery  and  this  ligature  slipped  and  the  patient 
bled  to  death,  the  surgeon  would  not  be  justified  in  condemning  the  general 
method  of  placing  ligatures  on  blood  vessels,  but  he  should  assume  that  the 
ligature  was  not  properly  tied.  If  a  ligature  "blows  off"  the  stump  of  an 
appendix  it  is  more  the  fault  of  a  carelessly  applied  ligature  than  a  reflection 
upon  the  technic  of  the  operation  that  the  surgeon  attempted  to  follow. 

Naturally,  this  method  of  treating  the  stump  of  the  appendix  does  not 
necessarily  apply  to  larger  wounds  of  the  intestine,  and  particularly  to  the 
treatment  of  the  ends  of  the  intestine  when  lateral  anastomosis  is  done. 
Where  the  wound  is  large,  and  bears  the  brunt  of  the  current  of  peristalsis, 
peritoneal  surfaces  must  be  approximated  and  ligation  is  not  applicable,  but 
in  the  appendix  where  the  aperture  is  small  and  does  not  receive  the  impact 
of  the  current  of  intestinal  contents  the  simple  method  that  has  been  de- 
scribed seems  excellent. 

AVhen  an  abscess  results  from  appendicitis  or  when  peritonitis  has  de- 


iSurg.    Gvn.   &   Obst.   Dec.    1914,   p.    791. 

^Jour.  Am.   Med.  Assn.,  Nov.   6,    1915,   Ixv,    1628-34. 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC.  635 

veloped,  drainage  is  necessary.  A  small  amount  of  murky,  thin  fluid  Avhen  the 
appendix  has  not  ruptured  does  not  call  for  drainage,  but  in  the  presence  of 
a  distinct  abscess  or  where  the  appendix  has  ruptured,  particularly  if  the 
clinical  symptoms  show  marked  reaction,  drainage  should  be  employed.  For 
acute  appendicitis,  particularly  if  there  is  to  be  drainage,  I  always  use  the 
McBurney  muscle  splitting  incision.  When  there  is  a  history  of  recurrent 
appendicitis,  or  of  a  so-called  chronic  appendicitis,  which  may  be  accom- 
panied by  other  lesions,  a  long  incision  near  the  median  line  is  made  unless 
the  diagnosis  can  be  quite  clearly  limited  to  the  region  of  the  appendix  and 
the  terminal  ileum.  Chronic  eases,  as  a  rule,  demand  more  thorough  ex- 
ploration than  can  be  done  through  a  muscle  splitting  incision,  but  in  acute 
appendicitis  the  McBurney  incision  offers  ample  space  for  removal  of  the 
appendix  and  makes  hernia  after  drainage  much  less  likely  to  occur  than 
if  a  long  rectus  incision  was  made.  It  is  unusual  to  find  a  hernia  in  drain- 
age cases  of  appendicitis  when  the  McBurney  incision  is  employed,  and 
even  if  it  occurs  it  usually  gives  but  little  discomfort  and  can  be  readily  re- 
paired; whereas  with  a  rectus  or  median  incision,  especially  if  there  is  drain- 
age, hernia  is  not  uncommon. 

After  making  the  McBurney  incision  and  opening  the  peritoneum  the 
presence  or  absence  of  free  fluid  is  noted.  The  finger  is  inserted  and  the 
appendix  is  located  by  palpation.  If  there  are  no  adhesions  the  cecum  is 
pulled  up  into  the  Avound  and  the  appendix  is  clamped  near  its  base,  if  it  is 
not  gangrenous  at  this  point.  If,  however,  the  appendix  is  adherent,  and 
particularly  if  it  is  gangrenous  and  ruptured,  it  should  be  carefully  isolated 
by  the  finger  and  brought  into  the  wound  with  as  much  gentleness  as  possi- 
ble to  avoid  any  further  spreading  of  the  infection.  Seizing  an  appendix  that 
is  strutted  with  pus,  or  that  has  become  gangrenous,  with  an  ordinary  pedicle 
forceps  is  unwise,  as  the  infiltrated  tissue  will  almost  certainly  be  cut  through 
like  cheese  and  the  bleeding  will  smear  the  pus  over  surfaces  that  other- 
wise might  not  be  infected.  Such  an  appendix  should  be  caught  with  light 
bladed  sponge-holding  forceps  with  corrugations  on  the  grasping  surface. 
The  forceps  are  not  locked  but  are  closed  just  sufficiently  to  hold  the  appendix 
while  drawing  it  into  the  wound.  Several  sponge-holding  forceps  are  used 
if  the  base  is  the  first  part  of  the  appendix  that  is  located.  The  first  forceps 
seize  the  appendix  near  the  base,  pull  it  up,  and  another  forceps  seize 
it  lower  down  and  make  further  traction  while  it  is  being  freed  from  the  sur- 
rounding tissues  with  the  fingers.  In  a  very  fat  patient  it  is  often  difficult  to 
recognize  an  infiltrated  appendix  because  a  fatty  tag  or  fold  that  is  infiltrated 
may  so  simulate  it  as  to  be  very  confusing.  If  the  finger  can  find  the  line  of 
cleavage  and  follow  this  without  too  much  force  the  tissues  can  usually  be  sepa- 
rated without  doing  any  material  damage.  When  an  obstruction  is  met  no  ef- 
fort should  be  made  to  punch  through  it  with  the  finger,  but  another  line  of 
cleavage  should  be  sought.  If  an  abscess  is  present  it  is  opened  with  the  finger 
to  the  outer  side  of  the  appendix  and  cecum  if  possible.  It  is  best  to  protect  the 
surrounding  structures  with  a  moist  gauze  pack  before  opening  it.     When 


636  OPERATIVE    SURGERY 

the  abscess  is  in  the  pelvis  or  Avlien  the  appendix  has  already  ruptured 
into  the  free  peritoneal  cavity  no  gauze  should  be  placed  in  the  abdomen. 
Walling  off  abscesses  with  gauze  is  not  so  frequently  done  now  as  it  was 
a  few  years. ago.  If  too  much  gauze  is  placed  in  the  peritoneal  cavity  and 
if  it  is  too  roughly  placed  it  may  do  more  harm  than  good. 

While  emptying  the  abscess  the  patient  is  turned  over  on  the  right  side 
for  a  few  minutes  and  the  finger  is  held  in  the  abscess  cavity  to  permit  the 
pus  to  drain  out  of  the  wound  by  gravity.  The  patient  is  then  turned  on 
his  back  and  the  abscess  is  gently  cleaned  until  it  is  dry  with  gauze  sponges 
in  sponge-holding  forceps.  The  stump  of  the  appendix  is  then  treated  in 
the  same  manner  as  in  recurrent  or  chronic  appendicitis.  Often  it  is  impos- 
sible to  tie  the  stump  of  the  mesentery  to  the  stump  of  the  appendix  because 
of  infiltration  with  inflammatory  products,  but  otherwise  the  technic  is  the 
same.  If  the  appendix  has  not  ruptured  but  seems  to  be  on  the  point  of  rup- 
turing, the  utmost  care  should  be  exercised  to  prevent  it  from  bursting  during 
the  manipulations  to  deliver  it,  and  the  wound  should  be  carefully  protected 
with  gauze. 

When  there  is  an  abscess  or  when  the  appendix  has  ruptured,  drainage 
should  always  be  instituted.  This  usually  consists  of  a  single  rubber  tube 
with  only  one  perforation  near  its  end  which  is  inserted  down  to  the  abscess 
cavity  or  into  the  culdesac  of  the  pelvis.  If  the  abscess  cavity  is  rather  large, 
and  particularly  if  there  is  much  bleeding  after  enucleating  the  appendix, 
the  raw  surface  is  packed  firmly  with  dry  gauze  that  is  left  in  place  about 
four  minutes.  This  permits  the  blood  to  clot  and  when  the  packing  is  re- 
moved the  bleeding  is  usually  controlled.  If  it  has  not  entirely  stopped  there 
will  be  only  a  few  bleeding  points  which  may  be  whipped  over  with  a  needle 
and  catgut  and  gently  tied,  or  which  may  be  controlled  by  placing  a  cigarette 
drain  down  to  the  bleeding  points.  When  the  abscess  is  behind  the  ce- 
cum there  is  a  great  tendency  for  the  bacteria  to  be  carried  to  the  poste- 
rior region  of  the  liver  unless  the  abscess  cavity  is  freely  opened  and  well 
drained.  Here  a  large  cigarette  drain  of  gauze  in  rubber  dam  is  carried  into 
the  abscess  cavity  and  in  addition  a  soft  rubber  drainage  tube  with  one  per- 
foration is  placed  in  the  pelvis.  The  drainage  tube  has  an  internal  diameter 
of  about  a  third  of  an  inch.  The  tube  is  sufficient  to  drain  off  the  accumulated 
material  in  the  peritoneal  cavity  and  to  cause  a  moderate  reaction  from  the  lym- 
phatics, whereas  the  gauze  that  is  carried  to  the  abscess  cavity  jDroduces  a 
much  more  profound  reaction  upon  the  lymphatics  and  consequently  a  more 
marked  reversal  of  the  lymphatic  circulation  toward  the  abscess  cavitj^  than 
the  rubber  tube  can  effect.  In  this  way  the  lymphatics,  instead  of  absorb- 
ing bacteria  from  the  walls  of  the  abscess  and  depositing  them  around  the 
posterior  region  of  the  liver,  will  pour  lymph  into  the  region  of  the  gauze 
drainage  in  an  effort  to  extrude  the  gauze.  These  features  of  drainage 
have  been  dealt  with  in  some  detail  in  the  chapter  on  Surgical  Drainage, 
but  their  application  is  particularly  important  here  in  order  to  prevent  sub- 
diaphragmatic abscess.     I  feel  that  if  this  precaution  is  taken  in  abscesses 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC.  637 

located  boliiiul  the  cecum  or  colon  a  sulxliaphragmatic  abscess  will  probably 
never  occur.  Since  adopting  the  measures  that  have  been  described  I  have 
not   had  a  patient  with  subdiaphragmatic  abscess. 

The  drainage  material  is  brought  out  at  the  outer  angle  of  the  wound. 
The  peritoneum  and  inner  portion  of  the  wound  may  be  partially  closed.  If 
only  a  rubber  tube  is  inserted,  which  is  usually  all  that  is  necessary,  except  in 
retrocecal  abscesses,  the  inner  portion  of  the  wound  in  the  peritoneum  and 
transversalis  muscle  can  ])e  closed  snugly  around  the  tube  Avith  two  inter- 
rupted sutures  of  catgut.  If  there  is  a  retrocecal  abscess  or  if  the  pus  is 
very  abundant  a  single  suture  of  silkworm-gut  is  placed  to  reinforce  the  in- 
ner j)ortion  of  the  wound.  This  is  not  tied  tightly  but  barely  approximates 
the  tissues.  The  tube  is  fixed  in  the  wound  by  a  single  silkworm-gut  suture 
in  the  skin.  The  rest  of  the  Avound  is  packed  lightly  with  iodoform  gauze 
in  order  to  prevent  pocketing  of  the  pus.  If  there  is  a  ciuantity  of  pus  and 
much  suturing  is  done  the  pus  is  very  likely  to  pocket  and  abscesses  in  the 
abdominal  wall  will  develop.  Later,  if  necessary,  the  wound  can  be  drawn 
together  with  adhesive  plaster.  Packing  the  wound  lightly  with  iodoform 
gauze  often  prevents  any  suppuration  in  the  raw  surface  even  though  pus 
drains  over  it,  because  the  gauze  causes  a  reversal  of  the  local  lymphatic 
circulation,  which  may  be  sufficient  to  prevent  infection. 

Patients  that  require  drainage  are  placed  in  bed  with  the  head  of  the  bed 
elevated  eighteen  inches.  The  extreme  Fowler  position  is  no  longer  used 
in  these  eases,  as  the  elevation  of  the  head  of  the  bed  seems  sufficient. 
The  patient  may  also  be  turned  slightly  to  the  right  side,  especially  for 
the  first  forty-eight  hours.  This  position,  however,  if  uncomfortable  need 
not  be  maintained.  The  stomach  is  washed  out  and  the  patient  is  given 
hot  water  by  mouth.  A  dram  of  bicarbonate  of  soda  and  half  an  ounce 
of  glucose  in  eight  ounces  of  a  one  per  cent  salt  solution  are  injected 
sloAvly  into  the  rectum  every  four  hours.  If  there  is  extension  perito- 
nitis continuous  rectal  saline  with  a  smaller  amount  of  glucose  and  soda  may  be 
used.  This  is  given  under  low  pressure,  but  if  very  disagreeable  to  the  pa- 
tient is  discontinued  and  given  at  intervals  of  four  hours.  In  very  ill  cases  hypo- 
dermoclysis  of  Locke's  solution  should  be  given  beneath  the  axilla.  If  the 
Locke's  solution  is  absorbed  too  sloAvly  or  causes  much  soreness,  it  may  be 
replaced  by  sterile  distilled  water,  or  the  distilled  water  may  be  given  for 
twelve  hours  and  then  the  Locke's  solution  for  twelve  hours.  The  objection 
to  using  liypodermoclysis  in  the  presence  of  pus  in  the  abdomen  is  that 
the  site  of  the  hypodermoclysis  may  become  infected  by  the  hematogenous 
transfer  of  bacteria.  The  method  here  described  may,  of  course,  be  used  for 
the  treatment  of  peritonitis  due  to  other  causes  than  appendicitis. 

PERICOLONIC  BANDS 

Bands,  or  veils,  or  kinks  about  the  terminal  ileum,  cecum,  ascending 
colon,  and  sigmoid  have  attracted  much  attention  in  recent  years.  The  Lane 
band,  which  occurs  in  the  terminal  ileum  usually  about  two  to  three  inches 
from  the  ileocecal  valve,  is  important.     The  veils  or  bands  about  the  cecum 


638  OPERATIVE   SURGERY 

and  ascending  colon  are  probably  less  likely  to  produce  symptoms  than  the 
Lane  band,  because  the  caliber  of  the  large  bowel  is  much  larger  than  of  the 
ileum  and  it  requires,  consequently,  greater  encroachment  on  the  lumen  of  the 
cecum  or  colon  to  produce  interference  with  the  flow  of  the  fecal  current.  Un- 
doubtedly, a  Lane  band,  which  reduces  the  caliber  of  the  ileum  to  a  third  of  its 
normal,  may  cause  colicky  pain  and  symptoms  that  are  often  attributed  to  ap- 
pendicitis. It  is  highly  important  in  every  case  of  recurrent  or  chronic  appen- 
dicitis to  examine  the  terminal  ileum  for  at  least  six  inches  from  the  ileocecal 
valve.  It  is  better  to  examine  it  for  several  feet  in  chronic  cases  in  order  to 
determine  whether  the  symptoms  may  be  due  to  a  Meckel  diverticulum. 

Attention  has  been  called  to  bands  and  veils  about  the  cecum  and  as- 
cending colon  by  Jackson,  of  Kansas  City,  whose  name  has  been  prominently 
associated  with  these  lesions  in  this  region,  just  as  Lane's  has  been  asso- 
ciated with  them  in  the  terminal  portion  of  the  ileum. 

J.  W.  Long,  of  Greensboro,  N.  C,  was  one  of  the  first  to  call  attention  to 
bands  or  veils  of  the  ascending  colon  or  cecum.  His  early  paper  on  this 
subject  was  read  before  the  American  Association  of  Obstetricians  and  Gyne- 
cologists, September  23,  1896,  and  appears  in  the  Transactions  of  that  year. 

In  women,  bands  or  adhesions  between  the  sigmoid  and  the  base  of  the 
left  broad  ligament  may  occur  with  almost  the  same  regularity  as  bands  in 
the  terminal  ileum,  cecum,  or  ascending  colon.  Hubert  A.  Royster,^  of  Ral- 
eigh, N.  C,  has  called  attention  to  the  bands  in  this  region  and  has  secured 
excellent  results  in  many  cases  of  left-sided  pain  by  recognizing  and  dividing 
these  sigmoid  bands. 

No  typical  operation  can  be  done  for  these  bands.  An  exact  etiology 
has  not  been  definitely  determined.  Many  investigators  from  embryologic  stud- 
ies assert  that  the  bands  are  a  perversion  of  normal  processes.  Though  due 
to  abnormal  embryologic  development  of  the  peritoneum  it  is  also  true  that 
their  effect  may  be  at  least  accentuated  by  irritating  or  inflammatory  proc- 
esses in  their  neighborhood  and  thus  a  vicious  circle  is  established.  Un- 
doubtedly bands  and  adhesions  may  occur  solely  as  the  result  of  peritonitis 
but  the  typical  bands  that  have  been  mentioned  seem  to  be  due  to  abnormal- 
ities of  development.  Hertzler*  deals  very  fully  with  the  anatomy  and  the 
embryologic  development  of  peritoneal  bands  and  ligaments  and  shows  how 
they  may  occur. 

If  they  are  causing  no  symptoms  and  there  is  no  degree  of  obstruction 
there  is  no  occasion  for  any  treatment.  If,  however,  the  bands  or  adhesions 
are  causing  symptoms  or  are  interfering  with  the  function  of  the  intestine  they 
should  be  divided.  The  method  of  division  depends,  of  course,  upon  the  lo- 
cation and  the  character  of  the  band.  The  Lane  band,  which  is  usually  nar- 
row and  spreads  out  in  a  fan-shaped  manner,  is  isolated  as  far  as  possible 
and  carefully  divided  with  blunt-pointed  scissors.  By  dividing  a  small  part 
of  the  band  at  a  time  and  making  it  tense  while  pushing  back  the  mesentery, 

3Tr.   Southern   Surg,   and   Gynec.  Assn.,   1909,  and    1912.  p.   97,   et   seq. 
^Hertzler:     The    Peritoneum,    St.   Louis,    C.   V.   Mosby    Co.,   i,    112,    et   seq. 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC.  639 

injury  to  tho  mesenteric  vessels  is  avoided.  Occasionally  a  blunt  instru- 
ment may  be  inserted  beneath  the  band  but  this  should  not  be  attempted 
unless  it  can  be  done  without  force,  for  otherwise  injury  may  be  done  to 
the  mesentery  itself.  After  division  of  the  bands  recontraction  at  least  to  the 
same  extent  as  existed  at  first  probably  does  not  occur,  but  in  order  to  ob- 
viate the  possibility  of  a  recurrence,  the  raw  surface  is  covered  by  approxi- 
matino-  the  mesentery  of  the  ileum  in  such  a  manner  that  it  will  make  a 
fold  of  the  mesentery  and  cause  the  mesentery,  where  it  was  uncovered  be- 
cause of  severina;'  the  Lane  band,  to  grow  together.  This  results  in  a  slight 
loop  of  the  ileum  which  is  sharp  but  does  not  interfere  with  the  function  of 
the  ileum.  A  band  to  the  cecum,  the  ascending  colon,  or  the  sigmoid  is  di- 
vided transversely  and  the  healthy  tissues  at  the  transverse  ends  of  the  incision 
are  approximated  by  a  few  sutures.  If  it  is  desirable  to  prevent  even  a  partial 
recurrence  and  if  the  tissues  cannot  be  satisfactorily  approximated  a  free  graft 
from  the  omentum  may  be  used  as  was  described  in  the  protection  of  the  in- 
jured duodenum. 

THE  TERMINAL  SIGMOID,  THE  RECTUM,  AND  ANUS 

Diseases  of  the  terminal  sigmoid  and  the  rectum  may  be  treated  as  in 
the  same  general  anatomical  division.  The  excellent  work  on  the  anatomy 
of  the  terminal  sigmoid  by  W.  J.  Mayo'"^  shows  that  in  the  terminal  two  inches 
of  the  sigmoid  there  is  a  distinct  change  in  the  anatomic  structure  which 
bears  considerable  resemblance  to  the  rectum  just  above  the  anal  canal.  There 
is  a  longitudinal  arrangement  of  the  mucous  membrane  at  the  end  of  the 
sigmoid.  At  the  beginning  of  the  rectum  there  is  a  rudimentary  sphincter 
which  forms  a  well  marked  resisting  constriction  to  the  readily  dilatable 
sigmoid  from  above  and  to  the  rectum  from  below.  It  is  here  that  cancer 
is  likely  to  occur. 

Operation  for  cancer  in  this  region  always  involves  removal  of  at  least 
a  portion  of  the  rectum  along  with  the  terminal  sigmoid.  As  the  first 
stage  of  this  operation  an  enterostomy  is  usually  done.  This  shovild  be  a  com- 
plete sigmoidostomy,  j)referably  Mixter's  operation,  so  as  to  divert  the  fecal 
current  entirely,  and  it  should  be  done  at  least  a  week  before  the  radical 
operation  for  the  removal  of  the  affected  bowel.  If  the  cancer  is  located 
on  the  proximal  side  of  the  rectosigmoid  junction,-  which  occasionally  occurs, 
and  is  not  far  advanced  it  may  be  removed  from  within  the  peritoneal  cavity 
by  a  thorough  mobilization  of  the  lower  sigmoid  and  upper  rectum,  followed 
by  an  end-to-end  union  of  the  intestine  and  later  a  restoration  of  the  con- 
tinuity of  the  fecal  current  by  uniting  the  bowel  at  the  site  of  the  sigmoidos- 
tomy. 

When  the  tumor  is  in  the  terminal  portion  of  the  sigmoid  and  the  patient 
is  not  too  fat  the  tube  method  of  Balfour  may  often  be  used  with  advantage 
without  a  previous  enterostomy.  The  sigmoid  is  well  mobilized  by  incising 
the  mesentery  along  its  outer  side  and  the  tumor  is  delivered  into  the  wound  as 


^Mayo,   W.   J.:     Surg.,   Gynec,   and   Obst.,    1917,   xxv,    616   to   621. 


640  OPERATIVE    SURGERY 

far  as  possible.  The  growth  is  excised  after  first  dividing,  clamping,  and 
tying  the  mesentery.  The  bowel  is  divided  at  least  two  inches  bej'ond  the 
apparent  margins  of  the  growth.  According  to  Handley  four  inches  is 
better,  as  the  cancer  cells  may  be  found  in  apparently  healthy  intestinal 
tissue  this  distance  beyond  the  obvious  limits  of  the  tumor.  A  rubber  tube, 
with  the  consistency  of  an  ordinary  rectal  tube,  but  with  an  internal  diam- 
eter of  about  one-half  inch,  is  inserted  into  the  proximal  end  of  the 
sigmoid  for  three  inches  and  is  fixed  by  a  suture  to  the  proximal  (oral) 
end.  A  pursestring  suture  is  placed  around  this  end  of  the  bowel  and  tied 
snugly  so  as  to  make  the  junction  between  the  tube  and  the  bowel  water 
tight.  The  lower  end  of  the  tube  is  introduced  into  the  distal  end  of  the  bowel 
and  protrudes  through  the  anus.  It  is  then  pulled  on  and  in  this  manner 
the  divided  bowel  is  approximated  and  is  united  by  sutures.  These  sutures 
may  be  of  chromic  catgut  and  the  first  row  should  co-apt  the  mucous  mem- 
brane accurately.  Further  traction  on  the  tube  induces  more  invagination 
which  may  be  assisted  by  steadying  the  lower  segment  of  the  bowel  with 
Allis  forceps.  Another  row  of  sutures  is  placed  to  hold  the  bowel  in  this 
position  and  under  further  traction  a  third  row  can  also  be  placed  if  neces- 
sary. If  the  omentum  is  available  it  is  fastened  around  the  line  of  suture 
with  a  few  stitches.  Fecal  matter  will  pass  through  the  tube  for  several  days 
until  the  danger  of  distention  from  gas  is  over.  This  method  is  valuable  in 
certain  cases  but  cannot  be  readily  used  when  there  is  an  excessive  amount 
of  fat  as  the  invagination  of  the  fat  may  produce  obstruction  or  necrosis. 

Cancer  of  the  upper  rectum  or  of  the  rectosigmoid  bowel  which  cannot 
be  eradicated  with  the  preservation  of  peritoneal  covering  on  the  distal  part 
of  the  bowel,  should  be  treated  by  the  two  stage  operation.  This  method,  as 
described  by  C.  H.  Mayo,  consists,  first,  in  an  exploratory  incision  near  the 
midline.  Through  this  incision  the  liver  is  examined  with  the  hand  and 
search  is  made  for  metastases.  If  there  are  a  few  enlarged  glands  Avhich  are 
not  fixed  and  appear  to  be  soft,  the  operation  is  not  contraindicated,  if  the 
growth  itself  can  be  well  mobilized  and  there  are  no  other  metastases.  After 
first  dividing  and  tying  the  mesentery,  the  sigmoid  is  clamped  and  divided  with 
an  electric  cautery  well  above  the  growth.  The  two  stumps  are  disinfected 
with  the  actual  cautery  and  the  ends  are  closed  by  a  continuous  mattress  suture.*' 
The  mesentery  of  the  lower  end  is  ligated  and  separated  from  the  sacrum  as  far 
down  as  possible  and  the  end  of  the  bowel  is  turned  into  the  culdesac  by  the  side  of 
the  growth.  The  pelvis  is  closed  off  by  suturing  the  back  of  the  bladder  in  the 
male  or  the  uterus  and  broad  ligament  in  the  female  to  the  posterior  parietal 
peritoneum.  In  this  manner  the  distal  end  of  the  bowel  including  the  cancer 
is  isolated  in  the  pelvis.  A  two-inch  incision  is  then  made  to  the  left  of  the 
midline,  splitting  the  fibers  of  the  rectus  muscle,  and  is  carried  through  the 
peritoneum.    The  proximal  end  of  the  boAvel  which  has  been  closed  by  sutures. 


^Mayo   Clinics,    1916,  p.   325. 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


641 


is  drawn  through  this  incision  and  sntnred  to  the  peritoneum  and  transver- 
salis  fascia  within  tlie  abdomen  by  slightly  everting  the  outer  edge  of  the 
wound.  Sutures  are  so  placed  that  the  closed  end  of  the  bowel  will  project 
about  one  and  a  half  inches  above  the  skin.  This  stump  is  twisted  three  quar- 
ters of  a  complete  turn,  as  advised  by  Lilienthal,  and  is  pushed  down  and 
sutured  to  the  anterior  sheath  of  the  rectus  muscle.  In  this  way  spiral 
valves  are  created  within  the  lumen  of  the  stump  of  the  sigmoid  and  this,  to- 
gether with  the  pressure  of  the  fibers  from  the  rectus  muscle,  gives  satis- 
factory control  over  the  bowel  movement.     This  makes  a  permanent  artificial 


Fig.  579. — The  Kraske  operation  for  excision  of  the  rectum.  The  coccyx  and  lower  portion  of  sacrum 
have  been  removed,  exposing  the  posterior  portion  of  tlie  rectum.  (After  technic  of  W.  J.  and  C.  H. 
Mayo.) 


anus  in  the  left  rectus  muscle  and  if  properly  attended  to  is  very  much  less 
inconvenient  than  it  is  usually  supposed  to  be. 

Six  days  later  the  second  stage  of  the  operation  is  done.  This  operation 
is  performed  according  to  W.  J.  Mayo's  modification  of  Kraske 's  operation. 
After  closing  the  anus  with  a  suture  an  incision  is  made  from  near  the  anus 
to  a  point  about  midway  between  the  middle  and  the  base  of  the  sacrum  on 
the  left  side.  The  soft  parts  are  dissected  free  and  retracted  from  the  coccyx 
and  the  lower  half  of  the  sacrum.     The  soft  tissues  attached  to  the  sides  of 


642  OPERATIVE   SURGERY 

the  sacrum  and  coccyx  are  separated  all  the  way  around  these  bones.  The 
sacrum  is  divided  transversely  with  a  chisel  about  the  second  foramen  and  the 
lower  part  of  the  sacrum  and  the  entire  coccyx  are  removed.  The  middle 
sacral  artery  may  require  ligation  (Fig.  579). 

In  mobilizing  the  sigmoid,  particularly  in  its  lower  portion,  care  must 
always  be  exercised  to  avoid  injury  to  the  ureters.  If  one  ureter  is  involved 
in  the  growth  or  if  it  is  injured  in  such  a  way  that  it  cannot  be  transplanted 
into  the  bladder,  its  upper  end  may  be  securely  tied  and  the  kidney  will 
eventually  atrophy  and  does  not,  according  to  W.  J.  Mayo,  give  any  further 
trouble.    Of  course,  the  other  ureter  and  kidney  must  be  normal  and  uninjured. 

In  dissecting  out  the  lower  portion  of  the  rectum  after  the  levator  ani 
muscles  are  well  defined,  the  hand  is  inserted  into  the  wound  and  the  struc- 
tures posterior  to  the  rectum  are  shelled  out,  keeping  close  to  the  upper  part 
of  the  sacrum  and  packing  the  cavity  with  hot  moist  gauze  in  order  to  pre- 
vent bleeding.  It  is  important  to  take  the  fat  surrounding  the  rectum.  The 
dissection  is  carried  laterally,  dividing  the  levator  ani  muscles  from  their 
lateral  attachments  to  the  pelvic  wall  after  first  clamping  them  with  large 
pedicle  forceps  in  order  to  crush  the  vessels.  Traction  made  on  the  loop  of  the 
bowel  which  is  drawn  into  the  wound,  greatly  facilitates  the  dissection.  The 
lining  of  the  anal  canal  is  dissected  out  from  below  as  in  the  Whitehead  oj^eration, 
and  the  whole  segment  of  bowel  along  with  the  attached  mucosa  of  the  anal  canal 
is  delivered  (Fig.  580) .  The  bleeding  vessels  are  controlled  by  being  whipped  over 
with  catgut  and  the  wound  is  closed  by  eliminating  dead  spaces  as  far  as  can 
be  done  without  tension  with  sutures  of  catgut,  lightly  packing  the  spaces 
that  remain  with  iodoform  gauze.  Drainage  is  brought  out  posteriorly. 
The  skin  wound  is  closed  with  interrupted  sutures  of  silkworm-gut. 

According  to  C.  H.  Mayo,  this  second  step  should  be  done  in  six  days. 
If  deferred  to  eight  or  ten  days  a  slough  often  occurs  and  there  may  be  leak- 
age of  the  intestinal  contents  or  infection  from  the  cancer.  Coffey's  method 
of  inserting  a  tube  through  the  rectum  up  to  the  divided  bowel,  fastening 
it  at  this  point  with  sutures,  and  then  inverting  the  bowel  and  pulling  it 
down  in  this  way  is  excellent  if  the  growth  is  sufficiently  small  to  permit 
the  tube  and  is  not  too  firmly  fixed. 

If  the  cancer  is  about  the  middle  of  the  rectum  it  may  be  removed  by 
the  Mayo  modification  of  the  Kraske  operation.  The  exposure  is  as  has  been 
described  in  the  second  stage  of  the  combined  abdominal  and  perineal  opera- 
tion. After  exposing  the  rectum  by  removing  the  coccyx  and  the  lower  part 
of  the  sacrum  at  the  second  sacral  foramen  the  rectum  is  mobilized  above  the 
disease  and  the  peritoneum  opened  anteriorly  and  packed  with  gauze.  The 
sigmoid  is  pulled  down  and  the  inferior  mesenteric  artery  is  divided  as 
close  to  its  origin  as  possible  in  order  not  to  interfere  with  the  numerous 
communicating  branches  in  the  distal  portion  of  the  mesentery  which  will 
permit  collateral  circulation.  The  two  folds  of  the  mesorectum  are  opened 
and  all  the  fat  and  fascia  adjacent  to  the  rectum  are  pushed  downward  by 


APPENDIX,    PERICOTvIC    BANDS,    RECTUM,    ETC. 


643 


gauze  dissection.  Its  lateral  attachments  are  clamped  and  cut.  The  bowel  is 
separated  in  front  from  the  bladder  and  urethra  in  man  or  from  the  vag- 
ina and  cervix  in  woman.  It  now  lies  attached  at  its  upper  and  lower 
ends.  The  bowel  is  doubly  clamped  and  divided  just  above  the  external 
sphincter  and  is  doubly  clamped  well  above  the  disease  and  divided  and  the 
diseased  segment  is  removed.  The  upper  stump,  which  has  been  clamped, 
is  disinfected  with  a  cautery,  ligated  with  stout  silk,  and  brought  down 
through  the  anus  an  inch  outside  of  the  anus.  It  is  important  that  there 
shall  be  no  tension  on  the  bowel.     If  there  is,  the  peritoneum  must  be  in- 


Pig.  580. — The  peritoneum  has  been  opened  and  the  lateral  attachments  of  the  rectum  have  been 
severed.  The  rectum  is  drawn  down  and  the  sigmoid  appears  in  the  wound.  The  prostate,  seminal  vesicles 
and  base  of  the  bladder  are  shown.      (After  technic  of   W.  J.   and   C.   H.   Mayo.) 

cised  more  freely  at  the  side  of  the  sigmoid  and  the  resisting  bands  severed. 
The  gauze  packing  in  the  peritoneal  cavity  is  removed  and  the  peritoneum 
is  attached  to  the  bowel  with  interrupted  sutures.  The  stumps  of  the  levator 
ani  muscles  are  sutured  to  the  posterior  surface  of  the  bowel.  Drainage 
is  provided  by  a  tube  and  a  cigarette  drain  and  the  rest  of  the  wound  is 
closed  with  interrupted  sutures  of  silkworm-gut.  The  lower  end  of  the  bowel 
may  be  left  ligated  for  two  days  or  sometimes  longer  with  but  little  discom- 
fort. This  will  add  greatly  to  the  healing  of  the  wound  without  infection. 
At  the  end  of  two  days  the  ligature  is  removed  or  if  the  patient  is  comfortable 


644  OPERATIVE    SURGERY 

it  can  be  left  in  position  still  longer.  When  it  is  removed  a  tube  is  placed 
in  the  bowel  which  will  conduct  off  most  of  the  discharges  and  so  lessen  the 
chances  of  infection. 

Often  so  much  of  the  bowel  is  involved  that  it  is  unwise  to  save  the 
sphincters.  Here  the  upper  end  of  the  bowel  may  be  brought  out  through 
the  upper  portion  of  the  sacral  wound,  though  this  makes  an  artificial  anus 
that  is  difficult  to  clean  and  is  unsatisfactory,  so  it  is  probably  better  to  es- 
tablish an  abdominal  anus.  If  this  is  done  it  should  be  according  to  the 
method  which  has  been  described  for  the  combined  abdominal  and  perineal 
excision  in  two  stages  in  which  the  upper  stump  of  the  sigmoid  is  brought 
through  the  split  fibers  of  the  rectus  muscle  and  twisted  three-quarters  of 
a  turn  in  order  to  aid  in  the  control  of  the  bowel. 

In  cancer  in  the  anal  canal  or  of  the  rectum  near  the  anus  the  operation  is 
performed  as  follows :  The  skin  around  the  anus  is  incised,  reflected  toward 
the  anal  canal,  and  fastened  with  a  ligature  or  suture.  From  this  incision 
around  the  anus  a  straight  cut  is  made  anteriorly  and  one  posteriorly.  The 
anus  and  rectum,  with  the  sphincters,  are  separated  from  their  surroundings, 
leaving  as  much  fat  and  fascia  attached  to  the  anus  and  rectum  as  possible. 
Pulling  on  the  ligatured  anus  aids  the  dissection.  The  rectum  is  mobilized 
by  inserting  the  fingers  posteriorly  and  stripping  the  tissues  from  the  coccyx 
and  lower  sacrum.  The  levator  ani  muscles  are  clamped  and  divided  on  the 
side  and  the  rectum  is  separated  in  front  from  the  urethra  in  the  male  as  in 
the  first  stage  of  a  perineal  prostatectomy.  A  sound  is  placed  in  the  urethra 
to  prevent  injury  to  the  urethra.  In  woman  the  posterior  vaginal  wall  may 
be  incised  to  aid  the  dissection.  The  bowel  is  brought  down  so  that  a  part 
of  the  rectum  which  is  two  inches  above  the  apparent  margins  of  the  growth 
is  flush  with  the  skin  of  the  anus  and  can  be  fastened  in  this  position  without 
too  much  tension.  The  stumps  of  the  levator  ani  muscles  and  the  clamped 
vessels  are  sutured  over  with  catgut.  If  possible,  the  rectum  is  twisted 
slightly  according  to  the  practice  of  Gersuny  in  order  to  aid  in  the  control 
of  the  bowel.  It  is  amputated  and  the  stump  fastened  to  the  skin  or  as 
near  the  skin  as  possible  with  interrupted  sutures  of  linen  or  silk.  If  can- 
cer of  the  anus  or  of  the  anal  canal  is  fairly  advanced  both  inguinal  regions 
should  be  dissected,  as  the  lymphatics  from  the  anal  canal,  especially  from 
its  external  portion,  go  chiefly  to  the  inguinal  regions. 

Occasionally,  in  early  cancer  of  the  rectum  when  it  is  low  down,  the 
anus  may  be  thoroughly  dilated  and  the  tumor  seized  through  a  speculum  and 
removed  with  an  electric  cautery.  Care  should  be  taken  to  manipulate 
the  tumor  as  little  as  possible  and  the  wound  should  be  closed  with  sutures 
of  stout  catgut  which  will  prevent  bleeding  and  which  are  inserted  in  such 
a  manner  as  to  decrease  the  caliber  of  the  boAvel  as  little  as  possible. 

Sometimes  when  the  growth  is  freely  movable  and  in  the  lower  part  of 
the  rectum  the  sphincter  muscles  may  be  preserved  by  merely  dissecting  out 
the  mucosa  from  the  lower  part  of  the  anus,  as  in  the  Whitehead  operation 
for  hemorrhoids.    After  going  above  the  region  of  the  sphincter  the  external 


Ari'KNDlX,    PERICOLIC    BANDS,    RECTUM,    ETC.  645 

layers  oC  llic  LoavcI  a\;i11  nrc  ciil  llii'ou^li  and  tlic  rectum  is  mol)ilized.  It  is 
then  pulled  down,  di\i(lc'd  ahoxc  Hie  caneer  tliroui>li  its  licallliy  portion  and 
sutured  to  the  skin. 

As  a  rule,  too  great  an  effort  is  made  to  preserve  the  function  of  the 
sphincter  in  operations  on  the  rectum.  In  a  very  early  growth  this  may 
sometimes  be  done,  but  not  infrequently  the  effort  to  preserve  the  sphincter 
leads  to  an  operation  that  is  not  sufficiently  complete,  and  consequently 
there  is  an  early  recurrence. 

In  cancer  of  the  rectum  where  as  much  as  eight  inches  of  the  bowel 
must  be  removed  and  where  the  lower  margin  of  the  cancer  is  about  two  and 
a  half  inches  from  the  sphincter  ani,  the  method  of  Kraske  is  a  satisfactory 
operation.  This  may  be  folloAved  b}^  bringing  the  bowel  through  the  anus  or 
by  a  sacral  anus,  though  a  permanent  colostomy  is,  as  a  rule,  more  satis- 
factory. 

If  dissection  can  be  safely  made  no  closer  than  two  and  one-half  inches 
to  the  anus  the  sphincter  may  be  saved  and  the  bowel  ends  may  be  united. 
The  ilpper  end  of  the  rectum  is  much  smaller  than  the  lower  end  and  is 
largely  surrounded  by  peritoneum.  The  upper  end  is  split  on  the  surface 
opposite  its  mesentery  for  about  one  and  a  quarter  inches  to  make  it  of  the 
same  caliber  as  the  lower  portion.  It  is  best  to  rotate  the  bowel  so  as  to 
bring  the  peritoneal  surface  posterior.  This  should  be  done  in  such  a  man- 
ner as  not  to  make  too  great  tension  on  the  mesenteric  border.  Half  a 
turn  of  the  bowel  Avill  secure  the  desired  position  and  at  the  same  time 
will  not  interfere  too  greatly  with  its  nutrition.  Through  and  through 
sutures  of  tanned  or  chromic  catgut  are  placed  so  as  to  invert  the  mucosa, 
and  over  this  a  second  row  of  interrupted  sutures  of  fine  silk  is  inserted. 
Melted  vaseline  if  poured  over  the  cavity  of  the  wound  seems,  accord- 
ing to  C.  H.  Mayo,  to  prevent  infection.  Drainage  from  the  dead  spaces 
is  provided  by  bringing  tubes  out  through  the  sacral  wound.  The  sphincter 
ani  is  divulsed  and  may  best  be  put  out  of  commission  by  dividing  it  anteriorly 
with  an  electric  cautery. 

In  small  early  cancers  in  the  anterior  wall  of  the  lower  rectum  the  pro- 
cedure as  practiced  by  Bevan'^  seems  excellent.  Of  course,  this  is  only  ap- 
plicable to  small  beginning  cancers  that  have  not  infiltrated  the  whole  wall 
of  the  bowel  and  are  in  the  lowest  portion  of  the  rectum.  The  patient  is 
placed  face  down  and  with  the  table  broken,  similar  to  the  Trendelenburg 
position,  only  the  patient  lies  on  his  abdomen  instead  of  on  his  back.  This 
position  is  useful  in  any  sacral  operation  on  the  rectum.  An  incision  about 
five  or  six  inches  in  length  is  made  from  the  lower  part  of  the  sacrum 
to  the  anus  in  the  midline.  The  coccyx  is  exposed  and  excised  from  the 
sacrum  with  bone  cutting  forceps.  The  tissues  on  each  side  are  retracted 
and,  beginning  at  the  anus,  posteriorly,  the  anus  and  rectum  are  divided 
upward  for  four  inches  (Fig.  581).  The  edges  of  the  wound  in  the  rec- 
tum are  caught  with  clamps  as  the  division  proceeds.     If  in  the  course  of 


'Surgical    Clinics   of    Chicago,    W.   B.    Saunders    Co.,    December,    1917,    p.    1233,    et    seq. 


646 


OPERATIVE   SURGERY 


dissection  no  metastasis  is  found  and  it  is  demonstrated  that  the  cancer  is 
early  and  has  not  penetrated  tlie  bowel  wall,  it  is  removed  with  an  electric 
cautery,  going  well  beyond  the  apparent  margins  of  the  growth  and  cutting 
througli  the  whole  Avail  of  the  rectum  until  the  areolar  tissue  beneath  is 
recognized  (Fig.  582).  In  a  male,  a  sound  in  the  urethra  prevents  in- 
jury to  the  urethra.  The  wound  left  by  removing  the  cancer  is  closed  by 
interrupted  sutures  of  linen  or  stout  catgut  in  a  large  curved  needle  which 
approximate  the  wound  and  control  the  hemorrhage  (Fig.  583).  The  pos- 
terior rectal  wound  is  closed,  beginning  at  the  upper  end  of  the  incision,  with 
interrupted  sutures  of  linen  which  are  tied  wdth  the  knots  inside  of  the  lumen 


y^ 


Tfed-rauJ'^       "rTo-rn     TSeva'o— 


Fig.    581. — Operation    of    ISevan    for    early    superficial    cancer    of    the    anterior    wall    of    lower    rectum, 
dotted  line  shows  the  site   of  the    incision. 


The 


of  the  boAvel.  Over  this  a  continuous  suture  of  tanned  or  chromic  catgut 
is  placed.  A  piece  of  iodoform  gauze  is  packed  into  the  rectum  over  the 
region  from  Avbich  the  cancer  was  removed  and  another  piece  is  placed  in 
the  upper  angle  of  the  skin  wound.  The  incision  in  the  skin  wound  is  closed 
with  interrupted  sutures  of  silkAvorm-gut. 

For  prolapse  of  the  rectum  the  patient  is  thoroughly  prepared  by  light 
diet  and  mild  purgatives  for  several  days  before  the  operation,  but  no  pur- 
gative should  be  given  for  forty-eight  hours  immediately  preceding  the  opera- 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


647 


tion,  during  \vliicli  time  the  bowel  is  emptied  by  soapsiid  enemas  and  the 
diet  restricted  to  liquids. 

The  operation  to  be  done  for  prolapse  of  the  rectum  depends  upon  the 
stage  of  the  disease  and  the  condition  of  the  patient.  In  children  most  cases 
can  be  cured  without  operation.  Attention  to  the  diet,  mild  laxatives,  and 
avoiding  strain  at  stool  will  often  effect  a  cure  in  young  children.  In  adults, 
a  fresh  prolapse  may  be  treated  by  replacement  and  by  strapping  the  buttocks 
together   with   adhesive   plaster.     An   incomplete    prolapse,   that   is,    one   in 


Fig.    582. — The    cancer   has   been   exposed   and   is   removed   with   an    electric    cautery.      (Bevan.) 

which  the  mucosa  descends,  or  a  complete  prolapse  in  which  all  coats  of  the 
rectum  come  down  but  with  the  sphincter  still  retaining  some  of  its  power, 
is  very  satisfactorily  treated  by  linear  cauterization  with  a  thermo  or  elec- 
tric cautery.  The  prolapse  is  pulled  down  as  far  as  possible  with  the 
patient  in  the  dorsal  position,  and  the  cauterization  begins  at  the  highest 
internal  point  of  the  prolapse,  continues  downward,  parallel  with  the  axis 
of  the  bowel,  and  terminates  just  above  the  sphincter.  The  cautery  should 
be  carried  through  the  mucosa  and  just  into  the  muscular  coat.  Four  or 
five  of  these  incisions  are  made  parallel  to  each  other  and  with  a  narrow 


648 


OPERATIVE    SURGERY 


strip  of  healthy  mucosa  between  each  line  of  cauterization  (Fig.  584).  The 
prolapse  is  then  reduced  and  the  protrusion  is  kept  above  the  grasp  of  the 
sphincter  by  suturing  the  anus.  Kellogg  Speed*  sutures  the  anus  with  a 
stout  silk  thread  in  a  curved  needle,  beginning  near  the  median  raphe  in 
front  and  passing  the  suture  completely  around  the  anus.  It  is  then  drawn 
tight  and  tied  so  that  not  even  a  grooved  director  can  be  inserted  into  the 
anal  canal.     Tlie  patient  remains   in  bed  and  has  a   diet  that  Avill  leave  as 


\ 


\ 


\ 


Tievs- 


Fig.  583. — The  wound  left  by  the  excision  of  the  cancer  is  closed  with  a  few  sutures.  The  posterior 
wall  of  the  rectum  is  united  with  interrupted  sutures,  tying  the  knot  within  the  lumen  of  the  bowel. 
(Bevan.) 

little  residue  as  possible.  He  is  given  a  grain  of  powdered  opium  by  mouth 
every  day.  At  the  end  of  a  week  the  pursestring  is  cut,  but  the  patient  is 
kept  in  bed  for  another  week,  being  given  magnesia  by  the  mouth  to  keep 
the  fecal  matter  soft,  and  using  a  bed  pan  for  the  bowel  movements. 

When  the  prolapse  seems  to  involve  most  of  the  lower  part  of  the  rectum 
an  incision  may  be  made  from  the  posterior  part  of  the  anus  to  the  coccyx. 


^Surgical   Clinics    of   Chicago,    W.    B.    Saunders    Co.,    February,    1920,    p.    68. 


APPENDIX,    PERirOLTC    BANDS,    RECT[TM,    ETC. 


649 


Tho  wall  of  the  i-ectiini  is  sutured  to  the  thick  fascia  and  ligaments  in  the 
neighborhood  and  a  reef  may  he  taken  in  the  levator  ani  muscles.  AVith  a 
complete  prolapse  and  weak  sphincter,  especially  in  elderly  people,  the  pro- 
lapse is  amputated  by  carefully  cutting  through  the  anterior  portion  of  the 
prolapsed  rectum  with  a  transverse  incision  near  the  anus  and  suturing 
the  part  of  the  bowel  near  the  anus  to  the  anterior  Avail  of  the  upper 
segment  of  the  prolapsed  portion  as  high  up  as  the  sutures  can  be  con- 
veniently placed.  Care  is  taken  to  avoid  injury  to  any  structures  that 
may  be  in  the  culdesac  and  to  prevent  soiling  the  peritoneum.  This  trans- 
verse incision  is  continued,  cutting  a  short  distance  at  a  time  and  immediately 
suturing  what  has  been  cut  until  the  whole  prolapsed  segment  has  been  re- 
moved. These  sutures,  which  are  of  linen  or  silk,  are  reinforced  by  a  continu- 
ous suture  approximating  the  mucosa  of  the  boAvel. 


Fig-.   584. — The  prolapse  of  the  rectal  mucosa  is  cauterized   with  electric  cautery. 

If  an  abdominal  operation  seems  wiser  the  operation  of  Moschcowitz  is 
satisfactory.  Here  a  median  abdominal  incision  is  made  from  the  pubis  to 
umbilicus  and  the  patient  is  placed  in  the  extreme  Trendelenburg  position. 
If  the  prolapse  is  in  a  w^oman,  linen  or  silk  sutures  are  passed  in  a  circular 
manner  around  the  culdesac  of  Douglas  and  tied.  The  lowest  suture  is  one 
inch  above  the  bottom  of  the  culdesac.  Six  or  eight  sutures  are  passed,  one 
above  the  other,  placing  as  many  sutures  as  necessary  to  bring  the  peritoneum 
together  without  too  much  tension  and  so  obliterating  the  culdesac  of  Doug- 
las. An  effort  should  be  made  to  secure  some  of  the  pelvic  fascia  in  each  of 
these  sutures,  particularly  over  the  levator  ani  muscles.  When  the  sutures 
reach  the  cervix  and  body  of  the  uterus  these  structures  are  included  and 
the  peritoneum  and  muscular  coats  of  the  rectum  are  also  grasped  in  each 
suture.     Care  should  be  taken  to   avoid  the  uterine  and  the  internal  iliac 


650  OPERATIVE   SURGERY 

vessels.  In  elderly  women  the  nterus  is  sewed  firmly  to  the  anterior  ab- 
dominal wall  after  the  culdesac  has  been  obliterated.  No  fixation  of  the 
colon  or  sigmoid  to  the  abdominal  wall  is  done,  as  this  is  useless.  The 
after-treatment  is  the  same  as  after  any  other  laparotomy,  Moschcowitz's 
operation  is  based  on  the  theory  that  prolapse  of  the  rectum  is  due  to 
relaxation  of  the  pelvic  fascia  which  permits  a  descent  of  the  rectum,  and 
that  sutures  placed  in  the  manner  indicated  will  take  up  the  slack  in  this 
fascia  and  afford  a  firm  support  because  of  the  close  attachment  of  this  fascia 
to  the  peritoneum  and  the  readiness  with  which  the  peritoneum  unites  when 
firmly  approximated. 

Abscesses  around  the  rectum  in  the  ischiorectal  fossa  should  be  opened 
as  soon  as  the  diagnosis  can  be  reasonably  made.  The  incision  is  so  made 
as  to  avoid  injury  to  the  sphincter,  the  finger  is  introduced  and  the  cav- 
ity explored.  The  various  compartments  are  gently  broken  down  and  the 
wound  is  lightly  packed  with  iodoform  gauze.  This  packing  is  changed 
at  intervals  of  two  or  three  days.  If  the  abscess  is  comparatively  small  it 
may  be  opened  under  local  anesthesia,  tube  drainage  instituted  for  a  few 
days  until  much  of  the  reaction  has  subsided  and  then  the  wound  is  gently 
packed  with  iodoform  gauze  which  has  been  soaked  in  five  per  cent  solution 
of  balsam  of  Peru  in  castor  oil.  The  bowels  are  kept  constipated  for  a  few  days, 
and  afterwards  mild  laxatives  are  taken  to  keep  the  bowel  movements  soft. 
Such  an  abscess  may  result  in  a  sinus  but  will  heal  in  a  short  time.  If  there 
is  communication  with  the  bowel  a  fistula  will  result,  but  if  the  sphincter 
is  cut  when  the  abscess  is  first  opened  an  unnecessary  amount  of  raw  surface 
will  be  exposed  to  the  pus  before  the  local  tissues  have  acquired  sufficient 
resistance  against  the  infection  and  serious  harm  may  be  done.  Inconti- 
nence will  frequently  follow.  After  the  fistula  has  well  formed,  however, 
operation  may  be  undertaken  with  the  hope  of  more  satisfactory  results.  A 
fistula  may  be  small  and  open  near  the  margin  of  the  anus.  The  opening 
usually  is  much  nearer  the  anus  than  it  is  supposed  to  be.  If  the  opening 
can  be  readily  demonstrated  the  old  operation  of  introducing  a  grooved 
director  and  splitting  the  tissues  over  it,  including  the  sphincter  at  a  right 
angle  to  the  sphincter,  gives  satisfactory  results,  provided  the  tract  of  the 
fistula  is  dissected  out  or  thoroughly  cauterized  with  the  actual  cautery. 
The  wound  is  packed  with  gauze  every  day  for  a  few  weeks  until  the  granu- 
lations have  become  healthy.  The  sphincter  should  always  be  cut  at  right  an- 
gles to  its  fibers.  If  cut  obliquely,  control  of  the  sphincter  is  often  lost, 
but  even  after  a  right-angle  section  incontinence  occasionally  results.  When 
this  does  occur  a  subsequent  operation  is  done  to  dissect  out  the  ends  of  the 
sphincter  and  unite  them  with  buried  sutures  of  fine  tanned  catgut. 

In  a  complicated  fistula,  particularly  of  the  horseshoe  type,  the  operation 
as  described  for  simple  fistula  is  unsatisfactory.  Complicated  fistulas  that 
arise  from  the  posterior  half  of  the  anus  almost  always  unite  at  a  common 
point  at  the  posterior  part  of  the  anus.  Here  the  sphincter  is  divided 
at  a  right  angle  to  its  fibers  and  the  various  tracts  are  made  to  communicate. 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC.  651 

Packing,  which  is  renewed  eveiy  day  or  every  two  days,  together  Avith  the 
usual  treatment  for  control  of  the  bowels,  is  carried  out. 

In  a  few  instances  the  tract  of  the  fistula  can  be  dissected  out  and  the 
wound  completely  sutured.  This  may  be  done  in  the  simpler  fistulas  where 
the  tract  is  well  organized  and  the  scar  tissue  around  it  presents  a  defi- 
nite tube.  In  a  complicated  fistula  if  the  opening  into  the  bowel  can  be  closed 
and  the  fistula  thereby  converted  into  a  sinus,  the  results  are  often  much  more 
satisfactory. 

The  operation  of  Elting  consists  of  mobilizing  the  mucosa  of  the  anal 
canal  and  lower  rectum  as  in  the  Whitehead  operation  for  hemorrhoids  and 
dissecting  it  free  for  a  short  distance  above  the  internal  opening  of  the  fistula. 
The  mucosa  is  drawn  down  and  the  excess  amputated.  The  mucosa  is  then 
fastened  to  the  skin  around  the  anus  with  interrupted  sutures  of  linen  or 
silk.  Only  the  mucous  membrane  with  its  submucosa  is  dissected  free  in 
this  operation  and  the  line  of  cleavage  should  be  carefully  observed,  for 
if  the  muscular  coat  is  included  the  operation  is  more  difficult  and  proper 
mobilization  cannot  be  effected.  The  chief  objection  to  the  Elting  operation 
is  that  stricture  may  result. 

E.  S.  Judd  has  modified  the  Elting  operation  by  making  the  incision 
only  half  way  around  the  circumference  of  the  anus  on  the  side  of  the  fis- 
tula and  extending  the  dissection  well  above  the  internal  opening  of  the 
fistula.  The  mucosa  of  the  bowel  on  this  side  is  pulled  down,  the  excess 
cut  away  and  the  stump  sutured  to  the  skin  of  the  anus  with  silk  or 
linen.  This  avoids  the  possibility  of  a  stricture  which  may  occur  after 
a  complete  circumferential  incision  of  the  anus  or  rectum.  The  rest  of 
the  fistula  will  usually  heal  readily  if  the  opening  into  the  bowel  has  been 
securely  closed.  The  fistula,  however,  may  be  enlarged  by  an  incision  parallel 
with  the  sphincter,  and  the  tracts  curetted  and  cauterized  or  dissected  out. 

In  a  fistula  where  the  tract  is  tortuous  it  is  followed  much  more  easily  if 
the  fistula  is  injected  with  some  dye,  as  methylene  blue.  This  is  done  by 
inserting  a  sharp-pointed  syringe  filled  with  methylene  blue  into  the  opening 
of  the  fistula  and  gradually  injecting  the  dye  until  the  fistula  is  well  dis- 
tended. The  syringe  is  held  in  position  for  half  a  minute  until  the  dye 
is  well  taken  up.  This  will  permit  the  easy  following  of  the  fistulous  tract 
which  is  opened  in  all  its  ramifications  and  cauterized  or  dissected  out. 
It  must  always  be  borne  in  mind,  however,  that  the  sphincter  should  never  be 
cut  but  once  and  then  at  right  angles  to  its  fibers. 

In  rectovesical  or  rectourethral  fistula  it  is  essential  to  drain  the  bladder, 
preferably  by  a  suprapubic  cystotomy,  before  attempting  to  close  the  fistula. 
The  fistula  may  be  then  closed  by  a  plastic  operation  involving  the  principle 
of  Elting,  which  has  been  very  successfully  used  by  Harvey  Stone,  of  Balti- 
more. The  mucosa  of  the  rectum  is  mobilized  to  a  point  Avell  above  the  open- 
ing of  the  fistula  into  the  rectum  and  a  few  sutures  of  catgut  are  placed  into 
the  urethral  opening  of  the  fistula.     The  cuff  of  the  mucosa  is  brought  down 


652  OPERATIVE    SURGERY 

to  the  anus,  the  excess  cut  off,  and  the  remainder  sutured  to  the  margins  of 
the  anus. 

Fissure  in  ano  is  an  ulcer  in  the  mucosa  of  the  anal  canal  and  is  usually 
found  along  the  posterior  border  of  the  anus.  It  is  about  half  an  inch  long. 
After  it  has  existed  for  a  short  time  the  tissues  around  it  become  indurated. 
There  is  considerable  spasm  of  the  sphincter  due  to  pain,  and  the  spasm  also 
causes  pain  and  prevents  healing,  so  that  a  vicious  circle  is  established.  The 
passage  of  fecal  matter,  together  with  the  more  or  less  constant  motion  of 
the  sphincter,  prevents  the  healing.  The  treatment  must  be  directed  to  se- 
cure rest  and  remove  the  conditions  that  cause  irritation.  The  sphincter 
ani  should  be  paralyzed  by  gradually  stretching  it  under  general  anesthetic, 
or  the  tissues  around  the  sphincter  may  be  carefully  infiltrated  with  one- 
half  of  one  per  cent  procaine  solution  and  divulsion  of  the  sphincter  can 
then  be  accomplished  with  but  little  pain.  The  injections,  however,  should 
be  made  not  only  in  the  si3hincter  but  around  the  anal  canal  for  a  distance 
of  an  inch  or  more  toward  the  rectum.  Under  local  anesthesia  the  fissure  may 
be  cauterized  with  an  electric  cautery  and  the  sphincter  partly  or  com- 
pletely divided  in  the  posterior  midline.  This  sometimes  is  a  more  satisfac- 
tory treatment  than  simple  divulsion,  as  it  can  be  done  more  readily  under 
local  anesthesia.  There  is  a  small  skin  tag  at  the  external  end  of  the  fissure 
which  is  called  a  sentinal  pile. 

Operation  for  ulceration  of  the  rectum  depends  upon  the  type  of  ulcera- 
tion. If  the  ulceration  is  extensive  the  sphincter  should  be  divulsed  or  di- 
vided, preferably  with  an  electric  cautery  at  its  anterior  or  posterior  commis- 
sure. The  posterior  division  secures  better  drainage,  though  the  division 
anteriorly  sometimes  heals  more  satisfactorily.  This  will  aid  the  healing  of 
an  ulcer  because  it  affords  rest  to  the  lower  part  of  the  rectum  by  preventing^ 
an  accumulation  of  gas  or  fecal  contents  Avhich  would  occur  when  the  sphincter 
is  intact.  Ulceration  due  to  cancer  should  be  treated  according  to  some  of 
the  methods  of  excision  depending  upon  the  stage  and  type  of  the  cancer 
and  also  upon  its  location.  Ulcers  due  to  syphilis  or  to  the  ameba  should 
have  specific  treatment.  Dysenteric  ulcers  that  are  high  up  in  the  rectum 
and  in  the  sigmoid  are  sometimes  treated  by  cecostomy  or  appendicostomy 
in  which  the  appendix  is  brought  up  through  an  incision  in  the  right  iliac 
fossa,  part  of  it  cut  away,  and  the  appendix  fixed  to  the  abdominal  Avound. 
Its  lumen  is  dilated  to  admit  a  catheter  through  which  liquids  having  a  sup- 
posedly therapeutic  effect  on  the  ulcer  are  introduced.  A  cecostomy  is  done 
by  using  the  technic  for  enterostomy  with  a  tube  introduced  through  the 
wound  for  irrigating  the  bowel.  These  operations,  hoAvever,  for  this  purpose 
are  being  generally  abandoned  because  fluids  can  be  introduced  through  the 
rectum  with  considerable  satisfaction,  and  also  because  the  irrigation  of  the 
ulcerated  areas  with  fluid  which  only  comes  in  contact  with  the  ulcers  for  a 
very  short  time  does  but  little  good  when  the  fecal  current  is  permitted  con- 
stantly to  bathe  these  surfaces.  If  any  operation  is  done,  it  should  be  a 
complete  diversion  of  the  fecal  current  and  this  is  best  accomplished  by  the 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC.  653 

John  Young-  Brown  operation  in  tlie  lower  ilenm  (p.  599).  The  distal  end 
of  the  ileum  can  be  used  for  irrigating  the  colon  and  cleaning  away  the 
fecal  contents  that  may  remain.  "Without  the  presence  of  the  fecal  cur- 
rent, irrigating  solutions  may  be  of  some  value. 

Strictures  of  the  rectum,  when  cancerous,  are  treated  by  resection  of  the 
rectum.  Stricture  is  particularly  likely  to  follow  a  circumferential  suture  of 
the  rectum  when  made  below  the  border  of  the  peritoneal  covering.  Stric- 
tures in  the  lower  portion  of  the  rectum  or  in  the  anal  canal  accompanied 
by  dense  tissue  may  be  divided  by  a  posterior  linear  proctotomy.  Here  the 
knife  is  introduced  above  the  stricture  and  a  deep  incision  is  made  posteriorly 
in  the  midline  almost  to  the  tip  of  the  coccyx.  Bleeding  is  controlled  by 
whipping  over  the  bleeding  surfaces  with  sutures  and  by  packing  with  gauze. 
B}'  making  an  incision  in  this  manner  drainage  is  facilitated  and  by  keep- 
ing the  incision  in  the  midline  the  danger  of  incontinence  is  usually  avoided. 
The  first  packing  must  be  placed  quite  firmly  to  control  hemorrhage,  but  after- 
wards the  packing  with  gauze  should  be  loose  enough  merely  to  fill  the  cavity 
lightly.  The  treatment  after  the  wound  has  begun  healing  consists  in  reg- 
ular dilatation  with  soft  rubber  bougies.  A  stricture  is  very  likely  to  oc- 
cur unless  dilatation  is  kept  up  for  several  months  after  healing. 

In  obstinate  strictures,  resection  of  the  lower  portion  of  the  rectum  by 
the  perineal  method,  or  even  the  Mayo-Kraske  operation,  may  be  justifiable. 
Ill  benign  strictures  that  are  uncomplicated  constant  dilatation,  preferably 
with  soft  rubber  bougies,  will  usually  effect  a  cure.  The  patient  can  be  in- 
structed to  pass  these  bougies  first  under  the  surgeon's  direction  and  later 
by  himself.  Metal  or  stiff  instruments  should  be  avoided.  The  bougies 
are  of  graduated  sizes. 

In  first  inserting  a  bougie  to  dilate  a  stricture  of  the  rectum  the  method 
of  Tuttle  should  be  employed.  A  proctoscope  is  introduced  up  to  the  stricture 
and  with  an  electric  light  attachment  the  opening  in  the  stricture  is  demon- 
strated and  the  rubber  bougie  is  accurately  inserted.  This  is  left  in  for  a 
few  minutes  and  a  larger  size  is  then  introduced.  Not  more  than  three  bougies 
should  be  inserted  at  the  same  sitting.  After  the  stricture  has  been  sufficiently 
dilated  the  bougie  may  be  passed  Avithout  the  speculum,  but  at  first  the  use 
of  the  speculum  and  the  accurate  passage  of  the  bougie  may  prevent  un- 
necessarj^  trauma. 

Bevan^  operates  in  strictures  that  are  low  down  by  dilating  the  stricture 
fully  under  a  general  anesthetic,  then  freeing  the  mucous  membrane  of  the 
rectum  to  a  point  just  above  the  stricture,  as  in  the  Whitehead  operation  for 
hemorrhoids,  and  bringing  it  down  and  uniting  it  to  the  anus.  If  dilatation 
ruptures  the  mucosa  at  the  site  of  the  stricture  and  makes  a  raw  surface,  the 
mucosa  above  the  stricture  is  brought  down  and  fastened  to  the  margins  of 
the  anus  with  mattress  sutures  of  silk  or  linen.  AVheii  the  stricture  is  Ioav  and 
narrow  this  procedure  may  be  applicable,  but  it  should  be  followed  by  passage 
of  bougies  or  dilatation  at  intervals  for  a  number  of  months. 


''Surgical    Clinics   of   Chicago,   W.    B.    Saunders   Co.,    February,    1918,   p.   u" ,   et   seq. 


654  OPERATIVE   SURGERY 

HEMORRHOIDS 

Hemorrhoids  are  divided  into  three  classes,  external,  internal  and  ex- 
ternointernal.  External  thrombotic  hemorrhoids  cause  a  great  deal  of  pain, 
which  is  readily  relieved  by  incision  and  turning  out  the  clot.  This  can 
be  done  painlessly  by  the  injection  of  procaine  solution  with  a  very  fine 
sharp  hypodermic  needle.  Before  injecting  the  solution  the  skin  over  the 
pile  is  touched  with  a  probe  that  has  been  dipped  into  pure  carbolic.  After 
w^aiting  one  or  two  minutes  the  hypodermic  needle  is  inserted  into  this  point 
and  there  is  usually  no  pain.  The  incision  is  made  in  a  radiating  manner  par- 
allel with  the  normal  folds  of  the  skin  about  the  anus.  After  the  clot  is 
turned  out  the  raw  surface  is  packed  with  iodoform  gauze.  If  these  clots 
are  left  they  may  organize  and  form  tags  which  are  sometimes  annoying. 

Internal  hemorrhoids  are  venous  or  capillary.  The  capillary  pile  is  cov- 
ered with  a  very  thin  layer  of  epithelium  and  bleeds  easily.  It  resembles 
a  raspberry.  Occasionally  a  polyp  is  found  which  is  thought  to  be  a  hemor- 
rhoid. Capillary  hemorrhoids  do  not  protrude  and  can  hardly  be  located 
by  touch.  They  bleed  on  contact  with  the  instrument  for  examination  and 
bleed  frequently  after  a  bowel  movement. 

The  venous  internal  hemorrhoid  comes  from  a  dilatation  of  the  vessels 
that  lead  to  the  superior  hemorrhoidal  vein  and  occurs  just  within  the  sphinc- 
ter. This  type  may  be  associated  with  venous  external  hemorrhoids  and  both 
can  be  treated  in  the  same  manner.  When  there  is  no  complication  about 
the  internal  hemorrhoid  and  the  sphincter  is  not  too  tight,  treatment  can 
often  be  carried  out  in  a  satisfactory  manner  by  the  method  of  injection  with  a 
solution  of  quinine  and  urea,  which  has  been  devised  by  E.  H.  Terrell,  of 
Richmond,  Va.  He  uses  a  solution  of  quinine  and  urea  of  three  to  five  per 
cent  strength  and  occasionally  as  strong  as  ten  per  cent,  the  weaker  solution 
being  given  in  the  first  injections.  Usually  there  are  three  hemorrhoids  to  be 
treated  and  one  is  injected  on  each  succeeding  day  until  all  are  treated.  If 
the  hemorrhoids  are  prolapsed  they  are  replaced  before  treatment  is  begun. 
The  hemorrhoid  to  be  injected  is  brought  into  view  through  a  small  conical 
fenestrated  speculum  and  is  painted  with  equal  parts  of  tincture  of  iodine  and 
alcohol.  Terrell  uses  a  very  small  needle  and  a  hypodermic  syringe  such 
as  is  employed  in  giving  tuberculin  so  that  it  will  not  block  the  vision.  The 
needle  is  inserted  well  into  the  substance  of  the  pile  and  the  solution  is  in- 
jected slowly  until  the  pile  is  slightly  distended.  The  needle  is  held  in  posi- 
tion a  moment  to  prevent  bleeding  at  the  point  of  puncture  and  is  then 
quickly  withdrawn.  On  the  following  day  the  hemorrhoid  on  digital  palpa- 
tion is  felt  to  be  thickened  and  indurated.  After  three  or  four  days  it 
begins  to  subside.  If  the  hemorrhoid  still  persists  after  ten  days  or  two 
weeks,  the  treatment  is  repeated,  using  a  slightly  stronger  solution.  This 
treatment  should  be  persisted  in  at  intervals  of  ten  days  or  two  weeks  until 
the  piles  have  disappeared.  There  is  practically  no  pain  from  the  treatment 
and  the  patient  is  permitted  to  pursue  his  usual  vocation,  though  it  is  usually 


APPENDIX,    PERICOLIC   BANDS,    RECTUM,    ETC.  655 

best  to  rest  for  a  few  hours  after  each  injection.  If  by  chance  the  solution 
is  injected  into  or  immediately  beneath  the  mucosa  instead  of  into  the  body 
of  the  pile,  ulceration  and  necrosis  may  occur,  but  this  accident  is  easily 
avoided  by  injecting  the  solution  into  the  upper  part  of  the  body  of  the 
pile  when  the  effect  of  the  quinine  and  urea  on  the  blood  vessels  and  sur- 
rounding tissues  will  not  extend  to  the  surface  of  the  mucosa. 

It  must  again  be  emphasized  that  the  Terrell  method  of  injecting  hemor- 
rhoids with  quinine  and  urea  solution,  which  has  just  been  described,  is  only 
applicable  in  uncomplicated  hemorrhoids,  that  is,  when  there  is  no  strangu- 
lation or  abscess  formation,  or  when  the  sphincter  is  not  too  tight.  It  may, 
however,  be  successfully  used  when  the  hemorrhoids  bleed. 

When  the  piles  are  large  and,  particularly  when  the  patient  desires  a 
quick  and  radical  cure,  operation  must  be  done.  There  are  three  different 
operations  that  under  different  conditions  are  applicable  and  are  followed 
by  good  results.  The  oldest  of  these  methods  and  one  that  is  frequently  em- 
ployed with  a  local  anesthetic  is  ligation  and  excision.  The  pile  is  caught 
with  forceps,  pulled  down,  and  the  mucous  membrane  at  its  lowest  border 
is  divided  with  scissors  close  to  its  junction  with  the  skin.  This  incision 
is  carried  upward  on  each  side  and  then  the  pile  is  separated  from  the 
tissues  beneath  by  inserting  the  scissors  closed  and  separating  the  blades. 
When  the  dissection  has  been  carried  upward  until  the  hemorrhoid  is  attached 
by  a  pedicle  composed  of  the  blood  vessels  and  a  small  strip  of  mucosa,  the 
pedicle  is  crushed  with  forceps  and  tied  with  linen  or  silk.  The  hemorrhoid 
is  cut  off  about  one-quarter  of  an  inch  below  the  ligature.  Each  hemorrhoid 
is  treated  in  a  similar  way,  taking  care  to  see  that  there  is  a  small  strip  of 
healthy  mucosa  left  between  each  hemorrhoid.  The  sphincter  ani  must  be 
dilated  for  this  operation,  though  not  as  thoroughly  as  would  be  necessary  for 
clamp  and  cautery.  General  anesthesia  would  be  preferable  if  there  are  sev- 
eral hemorrhoids  to  be  ligated.  The  objection  to  this  operation  is  that  it 
may  be  followed  by  infection  and  sometimes  by  secondary  hemorrhage.  The 
raw  surface  left  cannot  be  protected  from  the  bowel  contents  and  if  infection 
begins  and  abscess  formation  occurs,  complications  that  are  annoying  and 
sometimes  grave  may  arise.  When  the  operation  can  be  followed  by  rest  in 
bed  in  a  hospital  and  when  the  diet  is  regulated  and  careful  attention  is  paid 
to  the  after-treatment  these  complications  may,  as  a  rule,  be  avoided. 

One  of  the  most  satisfactory  operations  for  hemorrhoids  is  the  clamp 
and  cautery.  If  properly  performed  it  does  not  result  in  stricture.  After 
ligation  and  excision  there  is  a  certain  amount  of  necrosis  and  the  raw  sur- 
faces must  necessarily  be  bathed  with  fecal  matter,  but  with  the  clamp  and 
cautery  the  heat  sterilizes  the  tissues  and  seals  the  wound  with  an  aseptic 
eschar.  The  operation  is  simple  though  it  should  be  carefully  done  in  order 
to  secure  the  best  results.  After  thoroughly  dilating  the  sphincter,  each 
hemorrhoid  is  caught  at  its  apex  with  a  hemostat  and  dragged  well  down 
through  the  anus.  It  is  clamped  with  Ferguson's  pedicle  forceps,  parallel  with 
the  anal  folds  (Fig.  585).     These  forceps  have  blades  that  are  flat  and  hold 


656 


OPERATIVE    SURGERY 


the  hemorrhoid  firmly.  No  skin  is  included  within  the  bite  of  the  forceps.  It 
is  best  not  to  make  an  incision  with  scissors  or  a  knife  because  this  will 
leave  a  raw  surface  that  may  be  a  portal  of  infection.  The  object  of  the 
clamp  and  cautery  operation  should  be  to  have  the  whole  wound  thoroughly 
covered  with  an  aseptic  eschar.  With  a  little  care  a  good  hold  can  be  obtained 
upon  the  hemorrhoid  without  including  the  skin.  Usually  the  hemorrhoids 
are  grouped  in  three  locations  and  three  clamps  will  include  all  the  piles 
necessarv  to  be  removed.     It  is  particularly  important   to  see  that   there   is 


Fig.    585. — Clamp    and    cautery    operation    for    hemorrhoids.       The    hemorrhoids    have    been    clamped    with 
Ferguson  forceps  and  two  have  been   removed  with  cautery. 

a  broad  strip  of  healthy  mucosa  between  each  clamp.     If  this  precaution  is 
taken,  stricture  will  not  result. 

After  all  the  piles  are  clamped  the  last  one  is  pulled  down  so  the  tip 
of  the  Ferguson  forceps  emerges  from  the  aims.  To  protect  the  surrounding 
tissues  from  heat  wet  gauze  is  wrapped  around  the  base  of  the  hemorrhoid 
just  beneath  the  forceps.  In  the  original  operation  the  whole  hemorrhoid 
is  cauterized  with  the  actual  cautery.  This  is  necessary  Avhen  a  special 
pile  clamp,  such  as  Smith's,  is  used,  because  after  one  hemorrhoid  has  been 
cauterized  the  clamp  is  taken  off  and  applied  to  another.  In  this  way 
the  eschar  is  often  broken  by  the  manipulations,  and  bleeding  results.     The 


APPENDIX,   PERICOLIC    BANDS,    RECTUM,    ETC. 


657 


Foroiison  clamps,  however,  are  left  on  ;iiitil  the  completion  of  the  operation, 
hold  the  eschar  firmly  and  so  prevent  this  accident;  consequently,  time  can 
be  saved  and  satisfactory  results  obtained  by  cutting  off  the  hemorrhoid, 
if  it  is  large,  either  with  scissors  or  cautery  about  a  quarter  of  an  inch  from 
the  clamp.  The  tissues  being  thoroughly  protected  from  the  heat  with  wet 
gauze,  the  stump  of  the  hemorrhoid  is  cooked  with  a  thermo  or  an  electric 
cautery  at  a  low  heat.  The  cautery  is  applied  not  only  to  the  hemorrhoidal 
stump,  but  slightly  to  the  forceps  near  the  stump,  so  that  a  low  degree  of  heat 
will  be  conveyed  to  the  pedicle  of  the  hemorrhoid  that  is  within  the  grasp  of 
the  forceps.  About  one  minute  is  devoted  to  cauterizing  each  hemorrhoid. 
The  wet  gauze  is  removed  and  the  next  pile  is  treated  in  a  similar  way. 
After  each   cauterization  the   clamp  is  not  removed  but   its  tip   is  returned 


Fig.  586. — Clamp  and  cautery  operation  for  hemorrhoids.  The  hemorrhoids  have  been  removed  with 
cautery,  a  tube  is  inserted,  and  the  clamps  are  about  to  be  removed.  The  tube  is  usually  well  wrapped 
with  gauze  and  the  gauze   covered   with  rubber   dam.     This   is   not   shown   in   the   drawing. 

into  the  anus  and  gently  pushed  up  into  the  rectum  so  that  the  forceps 
will  be  out  of  the  way  while  the  next  hemorrhoid  is  being  treated.  After 
all  of  the  piles  have  been  cauterized  a  rather  firm  rubber  tube  about  three 
inches  long  and  one-third  of  an  inch  in  internal  diameter  is  wrapped  with 
iodoform  gauze,  covered  with  rubber  dam,  anointed  with  sterile  vaseline, 
and  inserted  into  the  anal  canal  (Fig.  586).  A  safety  pin  is  fixed  in  its 
outer  end.  Each  Ferguson  clamp  is  then  removed  gently  to  avoid  breaking 
the  eschar.  The  tissues  are  dusted  with  bicarbonate  of  soda  and  gauze  is 
wrapped  around  the  outer  end  of  the  tube  under  the  safety  pin  to  prevent 
the  safety  pin  from  pressing  on  the  anus.     A  strip  of  adhesive  across  the 


658  OPERATIVE   SURGERY 

buttocks  anchors  the  tube  and  safety  pin  more  firmly.  A  pad  and  a  T  ban- 
dage are  placed  over  the  end  of  the  tube.  If  the  cauterization  is  carefully 
done  and  if  the  tube  is  inserted  and  forceps  are  removed  without  breaking  the 
eschar,  there  is  practically  no  danger  of  hemorrhage  after  this  operation.  Stric- 
ture is  avoided  by  leaving  a  sufficient  amount  of  healthy  mucosa  between 
each  clamp.  The  scar  tissue  that  forms  after  a  burn  is  notoriously  greater 
than  that  from  an  incision  and  so  tends  to  obliterate  any  dilated  vessel  in 
its  neighborhood  that  may  not  have  been  caught  in  the  Ferguson  clamp.  The 
tube  gives  exit  for  gas  and  thus  makes  the  patient  more  comfortable.  Five 
or  six  small  punctures  in  the  skin  of  the  anus  about  half  an  inch  deep  along 
the  outer  border  of  the  sphincter  lessen  the  swelling  and  permit  the  escape 
of  serum  and  the  venous  blood  that  has  become  congested  in  the  tissues. 

The  Whitehead  operation  for  hemorrhoids  is  very  rarely  indicated.  It  is 
not  only  more  formidable  than  the  clamp  and  cautery  and  more  difficult  to 
execute,  but  is  peculiarly  likely  to  be  foUoAved  by  stricture,  which  is  a  much 
worse  affliction  than  hemorrhoids.  Occasionally^,  however,  in  very  aggra- 
vated types  of  hemorrhoids  when  their  borders  are  not  well  defined  and  par- 
ticularly when  they  are  associated  with  prolapse  of  the  mucosa  the  White- 
head operation  is  justifiable.  After  preparing  the  patient  in  the  usual  way 
and  dilating  the  sphincter,  several  large  hemorrhoids  are  clamped  with  for- 
ceps, pulled  down,  and  an  incision  is  made  around  the  anus  at  the  junction 
of  the  skin  and  mucosa.  The  mucous  membrane  is  separated  from  the  sphinc- 
ter by  inserting  the  scissors  with  closed  blades  and  spreading  them  open 
and  by  occasionally  cutting  any  marked  adhesion  that  may  be  present.  Blunt 
dissection  with  gauze  may  be  used  after  the  mucosa  has  been  partly  separated. 
In  this  manner  a  cuff  of  mucosa  from  the  anal  canal  and  lower  rectum  is 
pulled  down  for  about  three  inches.  This  includes  the  pile-bearing  area  of 
mucosa.  This  cuff  is  cut  away  in  small  sections,  beginning  in  front  with  a 
transverse  incision  of  half  an  inch  and  suturing  the  upper  edge  of  the 
mucosa  to  the  skin  with  interrupted  sutures  of  silk,  linen  or  stout  catgut. 
After  this  segment  has  been  sutured  the  incision  is  continued  for  another  half 
inch  and  this  part  of  the  mucosa  is  sutured,  and  so  on  until  the  whole  cuff 
of  mucosa  has  been  amputated  and  its  margin  has  been  sutured  to  the 
skin.  By  cutting  a  small  section  and  suturing  it  in  this  manner,  more  ac- 
curate approximation  is  attained  and  retraction  of  the  mucosa  is  prevented. 
If  there  are  any  bleeding  points  they  are  controlled  by  an  extra  suture. 
A  rubber  tube  is  prepared  and  inserted  as  after  clamp  and  cautery.  It  is 
also  well  to  make  a  number  of  short  stab  wounds  around  the  outer  margin 
of  the  anus,  a  procedure  which  has  been  advocated  and  practiced  by  C.  H. 
Mayo. 

Incontinence  of  feces  may  result  from  injury  to  the  sphincter  ani  either 
from  childbirth  or  following  operations  for  fistula.  After  the  inflammatory 
infiltration  has  subsided  this  condition  may  be  corrected  by  exposing  the 
ends  of  the  divided  sphincter  and  dissecting  them  for  a  distance  of  half  an 
inch  on  each  side.  They  are  then  approximated  with  a  mattress  suture  of 
fine  tanned  catgut  and  this  is  reinforced  by  two  or  three  other  sutures  of  the 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


659 


same  material.  Tlie  skin  is  closed  Avitli  a  continuous  mattress  suture  of  fine 
tanned  catgut.  A  mvdU  rubber, tube  is  introduced  through  the  anus  to  give 
exit  to  gas.  Tlie  patient  is  kept  constipated  for  five  or  six  days  or  even 
longer  if  possible  with  comfort.  This  can  l)e  done  by  giving  a  diet  that  Avill 
leave  but  little  residue,  such  as  albumens  and  broths,  and  by  administering 
paregoric  or,  if  necessary,  opium  or  morphine  when  there  is  an  inclination 
for  the  bowels  to  move. 

PRURITUS  ANI 

One  of  the  most  annoying  affeetioiis  of  the  rectum  that  require  opera- 
tion is  constant  itching.  This  may  be  so  severe  that  an  operation  is  de- 
manded in  order  to  relieve  the  patient  of  an  intolerable  situation.    Mild  cases 


Fig.   587.— A   sinus  in  the   anal   canal    (E.   H.   Terrell). 

may  be  relieved  by  ordinary  remedies  or  salves,  but  in  the  obstinate  cases 
of  pruritus  ani  local  applications  are  merely  palliative. 

E.  H.  Terrell,io  of  Richmond,  has  had  considerable  success  with  split- 
ting the  pockets  that  are  found  in  the  lower  end  of  the  anal  canal.  These 
lesions,  he  says,  are  sometimes  difficult  to  find  and  may  be  blind  pockets  or 
sinuses  with  their  openings  at  or  just  internal  to  the  anorectal  skin  line.  Little 
pockets,  or  diverticula,  as  anal  valves  in  this  region  are  frequently  normally 

"Terrell,  E.  H.:   Southern  Med.  Jour.,  February,  1920,  pp.  123-125. 


660 


OPERATIVE    SURGERY 


found  but  when  tliey  are  not  inflamed  or  infected  they  cause  no  trouble,  just 
as  a  normal  appendix  gives  no  symptoms.  "When,  however,  they  are  chroni- 
cally infected  they  are  apparently  a  focus  of  toxic  material  that  seems  to 
cause  the  itching.  A  bent  probe,  used  by  Terrell,  as  shown  in  the  illustration, 
will  often  demonstrate  these  pockets  or  sinuses  (Fig.  587).  If  the  diverticu- 
lum is  large  and  forms  a  pocket  instead  of  a  straight  sinus  its  lining  is  glis- 
tening in  appearance  in  its  upper  part,  which  is  very  distinct  from  the  pink 
mucous  membrane  immediately  above  it.     The  opening  of  the  pocket  should 


Fig.   588. — A   large   pocket   or   diverliculum   in   the   anal   canal    (E.    H.    Terrell). 

be  looked  for  at  the  anorectal  line. .  When  the  covering  of  this  pocket  is 
removed  an  ulcerated  area,  which  heals  slowly,  is  found  (Pig.  588).  Terrell 
removes  the  covering  of  the  pocket  with  an  electric  cautery.  Its  floor 
is  injected  and  incised  so  that  a  small  portion  of  the  superficial  sphincteric 
fibers  is  divided  to  promote  healing  as  in  fissure  in  ano.  When  there  is 
a  sinus  it  sometimes  begins  at  the  bottom  of  the  anal  valve  but  is  usually 
found  as  a  slight  xlepression  just  below  the  level  of  the  anal  valve.  A  bent 
probe  introduced  into  such  a  sinus  passes  down  under  the  skin,  ending  in 
a  blind  pocket  which  often  appears  as  a  tag  of  skin  or  an  external  pile, 
but  sometimes  causes  no  protuberance  (Fig.  587).  If  the  itching  is  localized 
to  one  part  of  the  anus,  only  one  sinus  usually  exists,  but  in  the  severer 
forms  Avhere  the  itching  is  general  around  the  anus  two  or  more  sinuses  or 
a  pocket  and  a  sinus  may  be  found.  It  is  necessary  to  remove  completely  the 
covering  from  the  pocket,  though  the  sinus  may  be  simj)ly  laid  open  from 


APPENDIX,    PERICOLIC    BANDS,    RECTUM,    ETC. 


661 


its  orifice  to  its  termination  luider  the  skin  and  any  redundant  skin  or  mucosa 
trimmed  away  (Fig.  589).  Opening  tlie  sinus  is  best  done  witli  a  small  elec- 
tric cautery.  The  wound  is  inspected  and  packed  so  that  it  heals  from  the 
bottom.  Healing  is  often  slow  because  of  the  contraction  of  the  sphinc- 
ter. The  operation  can  ordinarily  be  well  done  under  local  anesthesia,  but 
if  general  anesthetic  is  used,  the  sphincter  should  be  divulsed  which  will  un- 
doubtedly hasten  healing.  This  method  of  treatment,  which  has  yielded  such 
excellent  results  in  the  hands  of  Terrell,  requires  careful  searching  for  the 


Fig.   589.— Removal  of  the  covering  of  one   of  the   anal  pockets,   according  to   the  method   of  E-   H.   Terrell. 

pocket  or  sinus  under  a  good  light,  but  it  seems  far  preferable  to  operations 
which  are  devised  to  treat  the  symptoms  by  destroying  the  nerves  instead  of 
relieving  the  cause  by  removing  the  focus  of  infection. 


SACRAL  AND  COCCYGEAL  DERMOIDS 

Dermoids  or  coccygeal  cysts  are  not  infrequently  found  posterior  to  the 
anus.  If  they  have  become  infected  they  are  often  treated  as  a  fistula  and 
opened  into  the  rectum.  Such  an  operation,  of  course,  is  useless  and  never 
curative.  Excision  of  the  complete  sac,  including  the  epithelial  bearing  tissue, 
is  necessary  for  cure.  When  a  sacral  dermoid  appears  over  the  lower  part 
of  the  sacrum,  a  wide  excision  of  the  affected  tissue  is  necessary  for  cure. 
The  skin  should  be  closed  with  interrupted  mattress  sutures  of  silkworm-gut 
which  are  so  placed  as  to  evert  the  edges  of  the  skin  and  prevent  the  tendency 


662  OPilKATlVE    SURGERY 

to  a  folding  in  of  the  epidermis  along  the  edges  of  the  skin  wound,  whieh 
may  be  responsible  for  a  recurrence.  A  dimple  appears  over  the  tip  of  the 
coccyx  in  many  infants  and  in  about  five  per  cent  of  adults.  Sometimes  it 
is  so  deep  as  to  form  a  sinus  which  readily  becomes  infected.  Such  a  sinus 
should  be  treated  as  a  dermoid  and  the  epithelial  lining  completely  excised 
together  with  a  considerable  amount  of  surrounding  tissue.  If  this  is  not 
thoroughly  done  recurrence  must  be  expected.  Any  suspected  fistula  poste- 
rior to  the  rectum  should  be  examined  for  hair  and  the  history-  of  the  condition 
carefully  obtained.  If  the  patient  states  that  hair  has  been  passed  from  the  fistula 
it  must  be  regarded  and  treated  as  a  coccygeal  cyst  or  fistula,  and  not  as  a 
fistula  in  ano.  If  there  is  any  reasonable  doubt  as  to  the  diagnosis  it  is 
best  to  treat  the  condition  as  a  dermoid  and  not  as  a  simple  fistula  in  ano. 


GHAPTER  XXVIII 
OPERATIONS  ON  THE  KIDNEY,  URETER  AND  BLADDER 

THE  KIDNEYS 

Incisions  for  exj)osure  of  the  kidney  have,  been  mentioned  but  as  they 
are  so  important  in  the  technic  of  kidney  operations  they  should  be  con- 
sidered at  some  length.  Personally,  I  find  that  three  incisions  for  exposing 
the  kidney  cover  all  indications  for  operations  on  this  organ.  Two  are  lum- 
bar incisions.  The  simplest,  of  these,  the  vertical  incision  of  Simon,  may 
be  used  in  operations  for  fixing  the  kidney  or  for  a  simple  exploration  in  a 
thin  patient.  This  incision  is  made  along  the  outer  edge  of  the  erectbr  spinae 
muscle  and  goes  vertically  from  the  last  rib  downward  to  near  the  crest  of 
the  ileum.  The  fibers  of  the  latissimus  dorsi  are  separated  and  retracted  but 
not  cut.  The  erector  spin^e  muscle  is  retracted  inward  and  the  sheath  of 
the  quadratus  lumborum  is  opened  along  the  length  of  the  wound.  The  in- 
cision approaches  the  lower  rib  but  if  carried  too  close  to  the  rib  the  pleura 
may  be  injured.  This  accident,  however,  can  usually  be  avoided  by  pushing 
the  tissues  out  of  the  way  and  by  separating  the  tissues  chiefiy  by  blunt  dis- 
section up  to  the  lower  border  of  the  rib.  The  transversalis  fascia  is  recog- 
nized and  opened  at  the  upper  part  of  the  wound  and  the  fatty  capsule  of  the 
kidney  bulges  into  the  wound.  The  iliohypogastric  and  ilioinguinal  nerves 
lie  between  the  quadratus  lumborum  and  the  kidney  and  are  protected  by 
careful  retraction  outward  and  downward.  They  should  also  be  recognized 
when  the  wound  is  closed  so  they  will  not  be  included  in  the  bite  of  the 
suture.  This  incision  is  very  satisfactory  for  exposure  or  fixation  of  a  loose 
movable  kidney  in  a  thin  person  or  for  removal  of  a  stone  in  such  an  indi- 
vidual. As  a  rule,  however,  when  operation  for  stone  is  indicated,  or  when 
the  kidney  is  to  be  removed,  a  more  extensive  lumbar  incision  should  be 
made. 

The  lumbar  incision  of  W.  J.  Mayo  gives  excellent  exposure.  This  is  made 
by  beginning  about  two  and  one-half  inches  external  to  the  dorsal  spine  along 
the  outer  margin  of  the  erector  spin^  muscle  well  above  the  twelfth  rib. 
The  incision  is  carried  downward  and  slightly  forward  along  the  anterior 
margin  of  the  quadratus  lumborum  to  about  an  inch  above  the  crest  of 
the  ileum  Avhere  it  curves  forward  parallel  to  the  crest  of  the  ileum  (Fig. 
590).  It  is  carried  as  far  forward  as  the  indication  may  demand.  After 
dividing  the  skin  and  superficial  and  deep  fascia,  the  posterior  superior  lum- 
bar triangle  just  beneath  the  twelfth  rib  is  opened  by  cutting  through  the 
external  and  internal  ol)lique,  the  transversalis  and  the  latissimus  dorsi  mus- 
cles and  so  exposing  the  lumbar  portion  of  the  transversalis  fascia.    This  fascia 

663 


664 


OPERATIVE    SURGERY 


is  freely  incised,  the  ilioinguinal  and  iliohypogastric  nerves  are  identified 
and  retracted  out  of  the  way  and  the  lower  part  of  the  incision  is  completed. 
The  posterior  part  of  the  twelfth  ril)  is  cleared  backward  and  upward  al- 
most to  the  articulation  of  the  rib  with  the  twelfth  dorsal  vertebra  and  the 
pleura  is  pushed  upward.  When  the  attachments  of  the  quadratus  lumborum 
and  the  lateral  arcuate  ligament  which  jjinds  down  the  twelfth  rib  are  di- 
vided, the  twelfth  rib  can  be  retracted  upward  and  outward  Avhich  gives 
an  excellent  exposure.  The  edge  of  the  erector  spinae  muscle  is  retracted 
toward  the  spine.  This  incision  can  be  used  for  all  operations  upon  the  kidney 
in  which  the  kidnev  is   not   more  than   two   or   three   times  its   normal   size 


Fig.   590. — The  incision   of  W.   J.   ?iIayo  for  operation   on  the  kidney. 


and  where  the  procedure  is  more  extensive  than  merely  fixing  a  floating 
kidney  or  removing  a  small  stone  in  a  thin  patient. 

When  the  kidney  is  considerablj^  larger  than  normal,  and  especially  in 
large  tumors  of  the  kidney,  an  anterior  abdominal  incision  should  be  made.  This, 
called  the  incision  of  Langenbuch,  begins  just  below  the  rib  about  three 
inches  from  the  midline  and  is  carried  downward  along  the  outer  border 
of  the  rectus  muscle  in  the  linea  semilunaris.  The  peritoneum  is  opened 
and  the  opposite  kidney  is  examined  Avith  the  hand  before  proceeding  with 
the  operation.  The  colon  and  its  mesentery  are  retracted  toward  the  midline 
and  the  kidney  is  exposed. 

Nephropexy,  or  suturing  a  floating  kidney  in  place,  is  an  operation  that 


KIDNEY,    URETER,    AND    BLADDER 


665 


is  seldom  hulicnti'd.  It  formerly  had  great  vogue  and  many  symptoms  caused 
by  nervous  coiidilions,  or  l)y  stasis  or  intraabdominal  lesions  were  supposed 
to  be  due  to  a  movable  kidney.  Occasionally,  however,  when  excessive  mo- 
bility of  the  kidney  may  cause  it  to  be  damaged,  or  where  symptoms  result 
because  of  traction  or  twisting  of  its  pedicle  or  from  kinks  in  the  ureter 
nepliropex^y  is  indicated.  When  this  operation  is  demanded  the  patient  is 
always  thin  and  the  vertical  incision  of  Simon  can  be  satisfactorily  employed. 
After  exposing  the  kidney  with  the  patient  either  prone  or  well  over  on  the 
opposite  side,  the  kidney  is  delivered  into  the  wound  and  its  fatty  cap- 
sule which  is  scanty  in  these  patients,  is  stripped  backward  and  down- 
ward. It  should  not  be  removed  for,  as  has  been  pointed  out  by  Wil- 
lard  Bartlett,  if  the  fatty  capsule  is  shoved  to  the  lower  portion  of  the 
kidney  it  affords  some  support.     The  capsule  of  the  kidney  is  carefully  in- 


Fig.    591. — Nephropex}'.      The    sutures    for   fixation   liave   been   passed    and    the   kidney    is    ready 

to  be  returned  into  position. 

cised  in  the  midline  and  is  bluntly  stripped  until  about  tAvo-thirds  of  the  renal 
surface  is  exposed.  Four  sutures  of  tanned  or  chromic  catgut  are  placed  in 
the  capsule  as  mattress  sutures,  two  being  near  each  pole.  They  are  passed 
from  the  surface  next  to  the  kidney  and  close  to  the  reflected  capsule, 
catching  a  wide  bite  in  the  capsule.  The  needle  is  unthreaded  and  the 
ends  of  the  sutures  are  left  long  and  clamped  (Fig.  591).  The  kidney  is 
replaced  and  the  ends  of  the  upper  suture  are  threaded  into  large  curved 
needles  and  passed  through  the  abdominal  wall  from  within  outward,  pene- 
trating all  the  structures  except  the  skin.  The  needle  is  first  inserted  in  the  ex- 
treme upper  margin  of  the  wound  so  that  the  upper  pole  of  the  kidney  will 


666  OPERATIVE    SURGERY 

be  drawn  up  under  the  twelfth  rib  when  the  sutures  are  tied.  The  lower 
sutures  are  passed  in  a  similar  manner,  avoiding  the  ilioinguinal  and  ilio- 
hypogastric nerves.  The  sutures  are  tied  after  all  of  them  are  placed  and 
while  they  are  held  taut  to  bring  the  denuded  cortex  of  the  kidney  in  close 
contact  with  the  abdominal  wound  when  it  is  closed.  The  wound  is  closed 
Avitli  interrupted  sutures  of  catgut.  While  the  kidney  is  brought  Avell  up 
to  the  upper  angle  of  the  wound  it  is  still  not  as  high  as  it  would  normally 
be,  but  if  it  retains  the  position  in  which  it  is  sutured  the  result  will  be 
satisfactory  if  the  symptoms  have  been  due  to  the  mobility  of  the  kidney.  Some 
operators  advocate  fixing  the  kidney  by  passing  the  upper  sutures  around 
the  twelfth  rib.  This  should  not  be  done  unless  there  has  been  a  recurrence, 
or  unless  the  case  seems  to  require  unusual  measures.  Sutures  should  not 
be  passed  through  the  substance  of  the  kidney  itself,  as  they  will  cause  a 
destruction  of  a  certain  amount  of  renal  substance  and  this  tissue  does  not 
hold  sutures  well.  A  sufficiently  firm  grasp  can  be  obtained  by  passing  the 
sutures  through  the  reflected  capsule  of  the  kidney  as  mattress  sutures. 

In  nephrectomy  for  a  condition  in  which  the  kidney  is  not  much  above 
the  normal  size  the  lumbar  route  is  very  satisfactory.  After  exposing  the 
kidney  by  the  incision  of  Mayo,  the  fatty  capsule  is  split  and  bluntly  dissected 
away.  It  is  important  to  recognize  the  true  capsule  of  the  kidney  after 
splitting  the  fatty  capsule.  The  kidney  is  seized  with  the  hand  and  by 
gentle  traction,  delivered  into  the  wound.  By  strong  retraction  of  the 
abdominal  wound  the  pedicle  is  recognized.  Fat  is  carefully  separated  from 
the  renal  artery  and  vein.  If  the  pedicle  is  sufficiently  long  a  ligature  of 
catgut  is  carried  around  the  renal  artery  and  vein  together  and  tied.  The 
ligature  should  be  placed  as  far  from  the  kidney  as  possible  and  then  a  sec- 
ond ligature  toward  the  kidney  is  placed  half  an  inch  from  the  first  ligature. 
The  ureter  is  separated  from  the  rest  of  the  pedicle  and  a  clamp  is  applied 
to  the  renal  artery  and  vein  close  to  the  kidney  to  prevent  soiling  with  re- 
flux blood.  The  renal  vessels  are  divided  close  to  the  clamp,  leaving  the 
kidney  attached  solely  to  the  ureter.  As  much  of  the  ureter  as  is  thought 
necessary  is  stripped  up  and  the  ureter  is  doubly  ligated,  with  catgut  at  the 
lower  angle  of  the  wound  and  divided  between  ligatures,  preferably  with 
a  cautery.  Not  infrequentlj",  there  are  anomalous  polar  arteries  which  must 
be  identified  and  tied.  Often  when  the  pedicle  is  difficult  to  expose  it  can- 
not be  satisfactorily  ligated  before  the  kidney  has  been  removed.  Here 
the  pedicle  is  treated  by  seizing  it  with  two  forceps,  as  practiced  by  W. 
J.  Mayo,  after  the  ureter  has  been  divided  between  two  ligatures.  The 
stump  of  the  ureter  is  disinfected  and  in  tuberculosis  five  to  ten  minims 
of  carbolic  acid  are  injected  into  the  lumen  of  the  distal  part  of  the  ure- 
ter with  a  hypodermic  syringe.  This  in  the  practice  of  Mayo  has  been  sat- 
isfactory when  the  ureter  was  tuberculous  and  there  was  no  mixed  infection. 
It  is  better  to  inject  the  carbolic  acid  before  the  ureter  is  clamped  or 
tied.     The   portion   of   the   ureter   attached   to   the   kidney   is    dissected   up 


KIDNKY,    URETER,    AND    BLADDER  667 

well  to  the  pelvis  of  the  kidney  so  that  it  will  not  be  included  in  the  clamp 
on  the  pedicle.  As  much  fat  as  possible  is  removed  from  the  pedicle  and 
then  the  pedicle  is  clamped  with  two  forceps  about  three-quarters  of  an  inch 
apart  and  another  forceps  near  the  Ividney.  The  kidney  is  cut  away  by 
severing  the  pedicle  between  the  distal  two  forceps.  A  catgut  ligature  is  thrown 
around  the  pedicle  beneatli  the  deeper  pair  of  forceps  and  is  tied  as  this  clamp  is 
sloAvly  unlocked  so  that  it  sinks  into  the  groove  made  by  the  forceps.  A 
second  ligature,  which  is  placed  with  a  needle  that  transfixes  the  pedicle,  is 
tied  Avhile  slowly  removing  the  distal  forceps.  Both  ligatures  are  of  catgut. 
The  first  knot  is  single  and  may  be  held  with  mosquito  forceps  to  prevent 
slipping  Avhile  running  doAvn  the  second  knot.  If  the  nephrectomy  is  for 
sepsis  or  tuberculosis  the  infiltration  of  the  tissues  may  make  it  impossible 
or  unwise  to  ligate  the  renal  vessels  separately  and  the  support  of  the  sur- 
rounding tissue  which  has  been  crushed  by  forceps  in  the  manner  indicated 
adds  to  the  safety  of  the  ligatures.  If  on  account  of  the  obesity  of  the  pa- 
tient or  the  shortness  of  the  stump  it  is  impossible  to  apply  two  forceps,  one 
forceps  may  be  used  and  the  ligature  passed  through  a  margin  of  the  pedicle 
and  tied  in  a  single  knot  in  order  to  fix  it  in  position.  The  ends  of  the  liga- 
ture are  then  carried  around  the  pedicle  and  securely  tied  in  the  groove  left 
by  the  forceps.  This  procedure,  however,  W.  J.  Mayo  has  not  found  neces- 
sary in  ligating  the  kidney  pedicle  for  he  has  always  been  able  to  use  the 
two  forceps  method.  Occasionally  instead  of  a  ligature,  the  forceps  may  be 
left  on  and  removed  after  forty-eight  hours. 

The  treatment  of  the  pedicle  in  a  nephrectomy  is  an  exceedingly  impor- 
tant part  of  this  operation,  first,  because  of  the  control  of  hemorrhage,  and, 
second,  because  if  the  nephrectomy  is  done  for  a  malignant  tumor  of  the 
kidney,  fragments  of  this  tumor  may  project  into  the  renal  vein  and  if  the 
pedicle  is  not  carefully  dissected  and  secured  close  to  the  vena  cava  at  as 
early  a  stage  in  the  operation  as  it  can  be  exposed,  manipulations  may  dis- 
lodge some  fragments  of  the  growth  and  force  them  into  the  renal  vein. 
It  is  probable  that  this  accounts  for  the  early  hematogenous  metastases 
that  occur  after  nephrectomy  for  hypernephroma.  If  the  vessels  are  in- 
jured and  the  bleeding  is  profuse,  pressure  with  a  large  piece  of  dry  gauze 
should  be  made  immediately  over  the  bleeding  point.  If  this  controls  the 
bleeding  the  edges  of  the  gauze  are  gradually  removed  until  the  bleeding 
points  are  exposed  and  clamped.  If  the  hemorrhage  is  arterial  the  suggestion 
of  W.  J.  Mayo  should  be  followed  and  the  injured  vessel  siezed  with  the 
fingers.  Pulsations  of  the  artery  and  of  the  blood  stream  will  lead  the  fingers 
to  the  injured  artery.  A  clamp  can  then  be  applied  safely.  It  is  a  great  mis- 
take to  attempt  to  clamp  blindly  in  this  region  and  forceps  should  not  be 
applied  until  the  bleeding  point  has  been  accurately  located.  Injuries  to 
the  vena  cava  and  to  the  duodenum  from  indiscriminate  and  blind  clamp- 
ing may  occur  and  may  be  fatal. 

If  the  nephrectomy  is  for  a  kidney  that  is  infected  Avith  pyogenic  bacteria 
and  if  there  is  also  some  lesion  of  the  bladder  and  of  the  other  kidney  the 


668  OPERATIVE    SURGERY 

ureter  may  be  brouglit  into  the  lower  angle  of  the  Avound,  stitched  to  the 
skin,  and  left  open.  Mayo,  who  suggests  this  treatment,  says  that  the  ure- 
ter may  discharge  for  a  few  days  or  even  weeks,  but  will  soon  heal  sponta- 
neously in  most  instances  and  when  it  does  not  heal  it  can  be  removed  at  a 
secondary  operation.  This  treatment  of  the  ureter,  of  course,  is  only  in- 
dicated where  there  is  marked  infection  with  pyogenic  germs  and  where 
the  dropping  of  the  stump  of  the  ureter  into  the  depth  of  the  wound  may 
cause  infection  of  the  whole  wound.  Before  closing  the  wound  the  pedicle 
is  examined  and  the  Avhole  field  of  the  operation  reviewed  to  see  if  the  peri- 
toneal cavity  has  been  opened  or  any  injury  has  been  done  to  the  duodenum 
or  colon.  It  is  safer  to  apply  drainage  either  with  a  tube  or  a  cigarette 
drain  at  the  upper  angle  of  the  wound.  The  wound  is  closed  in  layers 
with  tanned  catgut,  using  a  continuous  lock  stitch,  or  with  interrupted 
sutures  of  silkworm-gut,  but  always  taking  care  not  to  include  the  ilioinguinal 
or  the  iliohypogastric  nerves  in  the  sutures.  If  there  is  no  infection  drainage 
can  be  removed  in  three  days. 

The  method  of  procedure  during  different  stages  of  lumbar  nephrectomy 
depends  largely  upon  the  indications  for  the  operation.  If  done  for  a  malig- 
nant growth  the  chief  point  is  to  expose  and  tie  or  clamp  the  renal  blood 
vessels  as  soon  as  possible  and  as  far  from  the  kidney  as  can  be  safely  done. 
This  Avill  prevent  metastasis  and  the  ureter  may  be  attended  to  later,  unless 
its  location  renders  it  difficult  to  secure  the  blood  vessels  of  the  pedicle  before 
scA'Cring  the  ureter.  When  there  is  marked  sepsis  a  double  catgut  ligature 
is  placed  on  the  ureter  as  far  from  the  kidney  as  possible  to  occlude  the 
ureter  and  prcA^ent  forcing  an  unnecessary  amount  of  septic  material  into 
the  bladder.  The  blood  A^essels  can  then  be  secured  and  divided,  leaA-ing 
the  kidney  attached  solely  by  the  ureter.  The  ureter  is  surrounded  by 
moist  gauze  and  divided  Avith  a  cautery  betAveen  the  ligatures  after  being  in- 
jected with  carbolic  acid.  The  changes  that  haA^e  been  indicated  may  be 
adopted  according  to  the  indications  that  arise. 

In  some  old  tubercular  kidneys,  or  in  old  infected  kidneys  Avith  stone,  de- 
livery of  the  kidney  into  the  Avound  is  exceedingly  difficult.  Here  subcap- 
sular nephrectomy  is  indicated.  If  there  has  been  no  previous  operation 
and  if  no  sinus  or  fistula  exists  the  lumbar  incision  is  made  doAvn  to  the 
capsule  of  the  kidney  and  the  capsule  is  split  along  the  outer  border  of  the 
kidney  and  stripped  doAvn  to  the  pelvis.  Here,  according  to  the  method  of 
Federoff  as  used  by  W.  J.  Mayo,  the  capsule  is  divided  near  the  pehas  of 
the  kidney  and  pushed  back,  leaving  the  capsule  attached  to  the  fat  and  the 
tissues  in  its  neighborhood.  The  ureter  is  doubly  ligated,  and  the  A^essels  of 
the  pedicle  are  exposed.  In  such  cases  it  is  occasionally  difficult  to  secure  the 
pedicle  by  ligature,  partly  because  of  the  infiltration  of  inflammatory  prod- 
ucts which  necessitates  the  subcapsular  method  of  removing  the  kidney. 
Here  the  pedicle  may  be  clamped  Avith  a  stout  pedicle  forceps.  The  clamp 
is  left  on  tAvo  or  three  days  and  is  then  unlocked  but  left  in  position  twelve 
hours  longer,  Avhen,  if  there  is  no  bleeding,  it  is  gently  removed. 


KIDNEY,    URETER,    AND    BLADDER  669 

When  the  kidney  is  niiieli  enhirged  and  particularly  from  malignant 
growths  the  nephrectomy  should  be  done  through  an  anterior  abdominal  incis- 
ion. Ample  exposure  is  made  by  the  incision  that  has  been  described  along  the 
linea  semilunaris.  The  peritoneum  at  the  root  of  the  outer  mesentery  of 
the  colon  is  incised  and  the  colon  with  its  mesentery  is  mobilized  by  gauze 
dissection  and  pushed  toward  the  midline.  The  intestines  are  kept  out  of 
the  way  and  protected  by  packs  of  warm  moist  gauze.  The  pedicle  of  the 
kidney  is  approached  if  it  is  possible  to  do  so  before  any  effort  is  made 
to  mobilize  the  kidney.  The  renal  vessels  are  exposed  by  careful  dissection 
and  tied  with  two  catgut  ligatures  half  an  inch  apart,  the  inner  ligature  being 
close  to  the  vena  cava.  The  vessels  are  next  clamped  near  the  kidney  and 
the  pedicle  is  divided.  If  this  procedure  is  impossible  on  account  of  fat 
or  infiltration  of  tissue  the  two  forceps  method  as  described  in  lumbar 
nephrectomy  is  used.  The  kidney  is  then  mobilized,  keeping  a  sharp  look- 
out for  anomalous  arteries  and  veins.  With  a  large  tumor  the  adhesions 
may  be  very  vascular  and  thin  walled  veins  often  develop  along  the  adhes- 
ions. The  ureter  is  doubly  ligated  and  divided  with  a  cautery  as  the  last  step  of 
the  operation,  though  it  may  be  well  to  place  a  double  ligature  around  the 
ureter  immediately  after  securing  the  pedicle  in  order  to  prevent  forcing 
infectious  or  malignant  material  into  the  bladder.  The  ureter  is  divided 
after  the  kidney  and  its  tumor  have  been  delivered.  With  a  sufficient  incision 
and  careful  exposure  it  is  not  often  necessary  to  tap  a  tumor  of  the  kidney 
before  its  removal  and  whenever  this  is  done  the  danger  of  infection  or 
metastasis  is  greatly  increased. 

The  wound  is  carefully  reviewed  to  see  that  no  accidental  injury  has  occurred 
and  all  bleeding  points  are  secured  with  catgut  ligatures.  Drainage  is  established 
by  inserting  a  pedicle  forceps  into  the  cavity  left  after  removing  the  kid- 
ney and  pushing  the  forceps  through  to  the  back  just  external  to  the  margin 
of  the  quadratus  lumborum  until  the  skin  is  reached.  The  skin  is  then  in- 
cised over  the  tip  of  the  forceps  after  separating  the  blades  and  the  forceps 
are  thrust  through  this  skin  incision  and  grasp  a  soft  rubber  tube  about  one- 
third  of  an  inch  in  diameter  which  is  drawn  into  the  wound.  The  tube  is 
fixed  to  the  skin  by  a  suture. 

The  tube  should  project  only  about  an  inch  into  the  cavity  left  by  re- 
moving the  kidney.  The  posterior  parietal  peritoneum  is  sutured  to  the  outer  di- 
vided layer  of  the  mesentery  of  the  colon  by  a  continuous  suture  of  catgut. 
The  abdominal  incision  should  be  closed  with  interrupted  sutures  of  coarse  silk- 
worm-gut. 

In  congenital  cystic  kidneys  the  disease  is  usually  bilateral  and  the  chief 
damage  is  probably  done  by  pressure  of  a  large  number  of  cysts  upon  the 
secreting  substance  of  the  kidney.  Lund  has  operated  successfully  in  such 
cases  by  exposing  the  kidney  and  puncturing  the  cyst  through  the  posterior 
surface  of  the  kidney.  As  the  cysts  are  punctured  the  kidney  diminishes  in 
size  and  can  be  delivered  into  the  wound,  when  other  cysts  are  palpated  and 
emptied  with  a  large  aspirating  needle  or  a  small  trocar  and  cannula.     The 


670  OPERATIVE   SURGERY 

kidney  is  returned  to  its  bed  without  drainage.  Because  congenital  cystic 
disease  of  the  kidney  is  usually  bilateral,  a  nephrectomy  sliould  never  be 
done  unless  it  has  been  thoroughly  established  that  the  condition  is  unilateral 
and  that  the  other  kidney  is  functioning  satisfactorily. 

Before  any  operation  upon  the  kidney  and,  particularly,  before  a  neph- 
rectomy is  done  the  condition  of  the  supposedly  healthy  kidney  should 
be  carefully  ascertained  by  catheterizing  the  ureters  and  examining  the  urine 
from  this  kidney.  Except  in  grave  emergencies  a  nephrectomy  is  not  justi- 
fied unless  this  is  done.  In  abdominal  nephrectomy  advantage  should  also  be 
taken  of  the  incision  to  palpate  the  healthy  kidney  before  the  diseased  one 
is  removed. 

In  nephrectomy  following  a  previous  nephrotomy  there  are  naturally 
many  adhesions.  After  making  the  usual  incision  and  surrounding  the  fistula 
the  capsule  is  best  reached  by  splitting  the  fistula  down  to  the  cortex  of  the 
kidney  and  then  stripping  the  capsule  and  proceeding  as  has  been  described 
with  a  subcapsular  iiephrectomy. 

Operations  for  stone  in  the  kidney  are  done  either  by  splitting  the  kid- 
ney and  extracting  the  stone  through  the  renal  cortex  or  by  pyelotomy. 
Splitting  the  kidney,  or  nephrotomy,  involves  considerable  hemorrhage  and 
destruction  of  some  of  its  parenchyma.  This  operation  should  be  reserved 
only  for  those  stones  deep  in  the  substance  of  the  kidney  or  for  very 
large  stones  that  cannot  be  extracted  through  the  pelvis  without  too  great 
damage.  The  average  stone  can  be  removed  from  the  pelvis  of  the  kidney  if 
satisfactory  exposure  is  obtained. 

The  kidney  is  exposed,  preferably  by  the  Mayo  incision,  and  is  delivered  into 
the  wound.  The  kidney  and  its  pelvis  and  ureter  should  be  palpated  to  determine 
the  pathology  present.  It  is  then  surrounded  with  moist  gauze.  Some 
operators  temporarily  clamp  the  pedicle  with  soft  forceps  or  surround  it 
with  a  rubber  band  to  prevent  hemorrhage  during  the  incision  into  the  kid- 
ney. It  has  been  shown,  however,  that  a  kidnej^  withstands  suspension  of  its  cir- 
culation very  poorly  and  such  measures  are  not  advisable.  If  the  hemorrhage  is 
profuse  an  assistant  can  usually  control  it  for  a  short  time  by  pressing  with  his 
fingers  on  the  hilum  of  the  kidney,  using  the  fingers  of  one  hand  in  front  and  of 
the  other  behind.  This  pressure  can  be  relaxed  if  necessary  to  restore  circulation 
or  altered  to  suit  the  circumstances.  If  the  Broedel  line  is  followed  the  hemor- 
rhage is  greatly  lessened.  Broedel  has  shown  that  the  arteries  in  the  cortex 
of  the  kidney  are  distributed  into  an  anterior  and  posterior  group  and  that 
the  anterior  group  is  wider  than  the  posterior.  The  A'essels  of  these  two 
groups  to  the  renal  cortex  are  smallest  in  size  and  least  in  number  on  a 
line  slightly  posterior  to  the  external  convex  border  of  the  kidney,  because 
the  anterior  group  of  vessels  supplies  a  little  more  than  half  of  the  organ. 
If  it  is  impossible  to  deliver  the  kidney  into  the  Avound,  as  sometimes 
occurs  in  fat  people  or  where  the  pedicle  is  short,  too  much  traction  must 
not  be  made  on  the  pedicle,  but  the  finger  is  passed  under  the  kidney  to 


KIDNEY,    URETER,    AND    I'.LADDKR  671 

bring  its  convex  bortler  into  tlie  wound.  An  incision  is  then  made  slightly 
posterior  to  the  apex  of  the  convex  border  and  just  long  enough  for  the  finger 
to  be  passed  into  tlie  pelvis.  The  stone  is  located  and  removed  with  forceps. 
The  wound  in  the  kidney  is  closed  with  interrupted  sutures  of  stout  plain 
catgut,  preferably  bringing  a  small  tube  out  through  the  middle  of  the  Avound 
but  suturing  the  kidney  substance  around  it  as  snugly  as  possible.  A  mat- 
tress suture  in  the  kidney  controls  the  hemorrhage  better  than  an  ordinary 
single  stitch  but  it  has  been  demonstrated  experimentally  by  James  E. 
Moore  and  J.  F.  Corbett  that  the  mattress  suture  produces  more  injury 
to  the  kidney  substance  than  a  simple  interrupted  stitch.  If  the  suture 
is  tied  just  snugly  enough  to  approximate  the  incision  and  the  first  tie 
of  the  knot  is  held  with  mosquito  forceps  w^hile  the  second  tie  is  being  run 
down,  hemorrhage  will  be  controlled,  the  kidney  wound  coapted,  and  a  mini- 
mum of  damage  will  be  done  to  the  kidney  substance.  If  too  much  tension  is 
put  on  these  sutures  they  cut  loose  and  cause  additional  hemorrhage. 

Thomas  Cullen  and  others  have  recommended  that  the  kidney  be  opened  by  a 
long,  blunt,  flat  needle  which  is  passed  through  the  kidney  from  pole  to  pole 
and  carries  a  fine  silver  wire.  The  kidney  is  cut  with  the  wire  from  within  out- 
ward with  a  minimum  amount  of  hemorrhage.  In  kidneys  where  there  is 
no  scar  tissue  this  method  is  excellent  when  it  is  intended  to  make  a  long 
incision  in  the  kidney,  but  when  scar  tissue  is  present  the  wire  will  cause 
more  trauma  than  the  knife.  It  is  not  always  necessary  to  open  the  kidney 
widely.  After  making  a  short  incision  to  admit  the  finger,  if  it  is  found  that  the 
stone  cannot  be  extracted  through  it,  the  incision  may  be  enlarged  following 
the  line  of  Broedel  either  with  the  knife,  or  with  a  wire  suture  as  suggested 
by  Cullen. 

Nephrotomy  for  abscess  is  sometimes  indicated,  though  nephrotomy,  as 
a  rule,  is  not  satisfactory  in  tuberculosis  of  the  kidney.  If  both  kidneys  are 
affected  with  tuberculosis  and  one  is  much  worse  than  the  other,  nephrotomy 
may  be  indicated,  but  sometimes  even  here  nephrectomy  gives  better  results. 

F.  S.  Watson  resorts  to  a  double  nephrostomy  where  it  is  necessary  to 
divert  the  urine  completely  from  the  bladder,  either  in  inoperable  malignant 
growths  of  the  bladder,  or  as  a  preliminary  to  total  excision  of  the  bladder. 
After  exposing  the  kidney  it  is  incised  through  Broedel's  line  and  a  tube 
is  inserted.  The  ureter  is  then  ligated  as  close  to  the  pelvis  of  the  kidney  as  pos- 
sible. After  the  fistulous  tract  into  the  kidney,  which  follows  the  drainage 
tube,  has  been  well  established  a  receptacle  devised  by  AVatson  is  used.  Es- 
sentially it  consists  of  a  cup  shaped  funnel  that  is  placed  over  the  fistula  and 
is  connected  by  a  rubber  tube  with  a  metal  receptacle  that  can  be  easily 
emptied. 

In  most  cases  of  stone  where  the  stone  is  not  very  large  the  operation 
is  best  done  through  the  pelvis  of  the  kidney.  It  is  necessary  to  deliver 
the  kidney  into  the  wound  and  to  expose  the  posterior  surface  of  the 
pelvis  by  turning  the  kidney  forward.      The   fat   over  the   pelvis   is   incised 


672 


OPERATIVE    SURGERY 


and  dissected  back  on  each  side.  It  should  not  be  cut  away,  as  W.  J.  Mayo 
has  shown  that  it  is  very  useful  in  covering  the  line  of  sutures  and  it  prevents 
leakage.  Before  opening  the  pelvis  the  tissues  around  the  kidney  are  thor- 
oughly protected  with  gauze  in  order  to  prevent  soiling  of  the  wound  with  the 
escaping  urine.  After  exposing  the  pelvis  it  is  incised  in  the  general  axis 
of  the  ureter.  The  incision  should  not  be  carried  too  close  to  the  kidney 
substance  because  large  vessels  may  be  injured  and  it  is  difficult  to  suture 
this  reo'ion  satisfactorily.     A  suture  of  fine  tanned  catgut  is  placed  in  each 


Fig 


592. — The  pelvis  of  the  kidney   has  been   opened  and  a  forceps   is   thrust   through   to  the   cortex,  where 

it  grasps  a  soft  rubber  catheter. 


lip  of  the  wound  in  the  pelvis  and  the  ends  are  left  long  to  act  as  tractor 
sutures.  The  incision  is  extended  until  it  is  large  enough  to  permit  explora- 
tion of  the  pelvis  and  extraction  of  the  stone.  The  stone  is  caught  wdth  for- 
ceps made  for  that  purpose  and  should  be  handled  gently  to  prevent  crush- 
ing it.  If  fragments  are  left  behind  they  may  form  a  nucleus  for  another 
stone,  so  it  is  important  to  remove  the  calculus  intact.  After  extracting 
the  stone  the  pelvis  is  explored  with  the  little  finger  if  the  opening  is  too 
small  to  admit  the  index  finger,  but  the  exploration  should  be  as  gentle  as  pos- 


KIDNEY,    URETER,    AND    BLADDER 


673 


sible  because  the  fiuo'er  eaii  easily  rupture  veius  about  the  calices  that  will 
cause  consitlerable  luMuorrliage. 

The  ]iext  step  of  the  operation  depends  on  whether  the  pelvis  of  the  kid- 
iu\y  is  to  be  drained.  The  great  objection  to  pyelotomy  is  that  if  a  drainage 
tube  is  placed  into  the  pelvis  of  the  kidney  the  fistula  that  results  is  some- 
times very  slow  in  closing.  Many  operators  practice  suturing  the  pelvis  with- 
out drainage  when  there  is  no  demonstrable  infection.  As  the  stone  is  of- 
ten the  result  of  infection  and  is  frequently  accompanied  by  infection  even 
though  it  is  mild,  it  seems  that  drainage  as  a  rule  would  be  beneficial.  This  is 
particularly  true  since  A.  J.  Crowell,  of  Charlotte,  N.  C,  has  shown  that 
lavage  of  the  kidney  pelvis  with  silver  solution  carried  out  for  some  time 
after   removal   of   the    stone    appears   to   prevent    its   recurrence.      Drainao-e 


Fig.    593.— The   catheter   is   drawn   through   so    that   its    tip    barely    rests   in    the    pelvis    of    the   kidney.      The 
catheter  is  fastened  to  the  capsule  of  the  kidney  with  a  single  stitch. 

of  the  pelvis  of  the  kidney  is  best  provided  by  inserting  a  small  blunt 
pedicle  forceps  through  the  wound  in  the  pelvis  and  thrusting  it  up  through 
the  substance  of  the  kidney  toward  the  middle  point  of  Broedel's  line,  where 
it  is  shoved  through  the  cortex.  A  new  soft  rubber  catheter  with  one 
or  two  additional  perforations  cut  near  the  end  is  caught  and  the  tip  of 
the  catheter  is  drawn  through  into  the  pelvis  of  the  kidney  (Fig.  592). 
The  tip  should  rest  well  within  the  pelvis  but  not  far  enough  down  to  occlude 
the  ureter.    It  is  fastened  in  position  by  a  mattress  suture  of  fine  tanned  catgut 


674  OPERATIVE   SURGERY 

which  passes  through  the  capsule  of  the  Ividney  and  then  through  the  wall  of 
the  catheter  (Fig.  593).  The  incision  into  the  pelvis  is  closed  by  a  continuous 
suture  of  fine  tanned  catgut.  The  fat  and  fascia  which  were  dissected  from 
the  pelvis  are  brought  together  over  the  suture  line  and  fastened  with 
a  few  interrupted  catgut  sutures.  The  packing  is  removed  and  a  small  ciga- 
rette drain  is  carried  down  to  near  the  pelvis  of  the  kidney  to  conduct  away  any 
urine  if  there  happens  to  be  leakage.  Both  the  cigarette  drain  and  the  catheter 
are  brought  out  at  the  upper  portion  of  the  wound  and  the  wound  is  closed  in 
the  usual  manner.  The  catheter  is  connected  to  a  bottle  to  prevent  soiling  of 
the  dressing  and  if  there  is  much  infection  in  the  pelvis  of  the  kidney  the 
catheter  is  kept  in  position  three  or  four  weeks  and  after  a  few  days  installa- 
tions of  silver  solution  are  made  into  the  pelvis.  In  this  manner  we  have  the 
advantage  of  the  incision  through  the  jDelvis,  together  with  drainage  of  the 
pelvis,  but  without  the  prospect  of  a  prolonged  fistula  which  may  occur  if  the 
drainage  is  inserted  into  the  wound  in  the  pelvis.  At  the  same  time  the 
catheter  introduced  in  the  manner  indicated  causes  almost  no  destruction 
of  the  renal  parenchyma  and  only  a  very  small  amount  of  bleeding.  Usually 
there  is  no  leakage  around  the  catheter  and  the  wound  can  be  kept  dry. 

Aside  from  the  extraction  of  stones  pyelotomy  is  but  seldom  indicated. 
Occasionally  pyelitis  demands  drainage  in  this  manner,  but  as  a  rule  the  urol- 
ogist can  treat  pyelitis  satisfactorily  by  catheterizing  the  ureters  and  lavage 
of  the  pelvis.  The  beneficial  action  of  catheterization  of  the  ureters  may  be 
due  to  the  dilatation  of  the  ureter  which  makes  better  drainage  from  the 
pelvis.  Hunner,  of  Baltimore,  has  obtained  satisfactory  results  in  many 
types  of  obscure  pain  merely  by  dilating  strictures  of  the  ureter. 

Hydronephrosis  was  formerly  treated  by  plastic  operations.  Various  op- 
erations have  been  devised  for  the  infolding  of  the  hydronephrotic  sac  or 
for  the  removal  of  a  valve  or  a  lateral  anastomosis  of  the  ureter  to  the  lower 
portion  of  the  hydronephrotic  sac.  These  operations  have  been  on  the  whole 
disappointing.  Occasionally  the  hydronephrotic  sac  may  be  drawn  up  onto 
the  kidney  around  its  whole  circumference  and  stitched  to  the  capsule  of 
the  kidney.  The  kidney  is  thus  invaginated  into  the  sac.  This  procedure, 
which  is  recommended  by  C.  H.  Mayo,  lessens  the  cavity  of  the  hydronephrotic 
sac  and  tends  to  straighten  kinks  and  folds.  Even  here,  however,  recur- 
rence of  the  hydronephrosis  occurs.  Sometimes  hydronephrosis  is  due  to 
plugging  of  the  ureter  with  a  stone  or  to  a  kink  from  adhesions,  or  from  a  low 
artery  of  the  kidney  which  produces  a  fold  in  the  ureter  just  after  the  ureter 
leaves  the  pelvis  of  the  kidney.  Obviously,  such  obstructions  must  be  removed  and 
if  a  stricture  is  found  it  may  sometimes  be  corrected  by  incising  the  stricture 
longitudinally'  and  suturing  the  wound  transversely  to  the  axis  of  the  in- 
cision, which  is  a  common  principle  in  plastic  surgery.  The  excision  of 
so-called  valves  is  usually  unsuccessful  in  producing  a  cure.  If  there  is  no 
obstruction  that  can  be  demonstrated  and  if  the  opposite  kidney  is  sound 
nephrectomy  offers  the  best  solution  of  the  problem. 


KIDNEY,    URETER,    AND    BIjADDER 


G75 


THE  URETER 

Oj)oratioiis  upon  llio  iirolci'  e(ni,sist  in  incising'  a  stricture,  in  delivery  of  a 
stone,  in  suturing  a  avouiuI  in  the  ureter,  in  uniting  the  ureter  when  divided, 
or  in   transplanting  it. 

A  stricture  of  the  ureter  is  best  treated  by  gradual  dilatation  if  it  can  be  en- 
tered by  a  bougie  or  catheter.  If  the  stricture  is  in  the  lower  end  of  the  ureter 
just  as  it  enters  the  bladder  and  it  is  imjiossible  to  pass  a  bougie  or  catheter,  the 
ureter  is  exposed  and  incised  about  the  brim  of  the  pelvis.  This  may  usually 
be  done  through  a  muscle  splitting  incision.  An  attempt  is  made  to  pass 
a  sound  or  bougie  from  above  downward  and  if  this  is  impossible  a  stout 
probe  is  introduced  to  the  stricture  Avliich  lies  close  to  the  bladder.  The  blad- 
der is  then  opened  by  a  suprapubic  cystotomy  and,  with  the  finger  in  the  blad- 
der, the  probe  is  gradually  shoved  through  into  the  bladder  and  out  at  the  su- 
prapubic wound.  Two  stout  linen  or  silk  threads  are  tied  to  the  end  of  the 
probe  and  the  probe  is  withdrawn,  pulling  the  threads  along  with  it.     Both 


Fig.  594. — A  stricture  of  the  lower  end  of  the  ureter.  A  communication  has  been  established  with 
the  bladder  by  the  method  described  in  the  text,  and  a  large  silver  wire  or  a  ureteral  catheter  is  drawn 
through. 


of  these  threads  are  long  and  the  ends  of  one  of  them  are  tied  together.  The 
other  serves  as  a  guide  to  carry  through  either  a  large  silver  wire  or  a 
ureteral  catheter,  which  is  passed  from  the  wound  in  the  ureter  downward 
through  the  bladder.  If  desired,  a  larger  catheter  can  be  passed  after  a 
few  daj's.  On  account  of  the  possibility  of  sepsis  a  stout  silver  wire  probably 
does  as  well  as  the  catheter  and  is  less  likely  to  produce  infection.  The 
wound  in  the  ureter  is  drained  by  a  cigarette  drain  which  comes  out  at  the 
abdominal  wound  (Fig.  594).     If  a  ureteral  catheter  is  used  it  should  not 


676  OPERATIVE    SURGERY 

be  permitted  to  stay  in  place  more  than  a  weelc  and  is  tlien  succeeded  Ly  a 
silver  wire  for  the  rest  of  the  period  of  drainage.  After  two  or  three  days  the 
catheter  or  Avire  is  gently  sawed  back  and  forth  to  widen  the  tract.  This  pro- 
duces a  large  fistula  between  the  ureter  and  the  bladder  slightly  to  the  distal 
side  of  the  stricture.  Of  course,  the  stricture  must  be  in  a  location  where  the 
ureter  either  enters  the  bladder  wall  or  is  in  juxtaposition  to  the  bladder. 

In  operations  for  stone  in  the  ureter  the  stone  is  localized  by  roentgen 
rays,  the  ureteral  catheter,  or  both,  and  an  incision  is  made  at  a  point 
where  the  stone  will  be  most  accessible.  Frequently  the  stone  is  found  in 
the  ureter  just  as  it  crosses  the  brim  of  the  pelvis  or  further  down  just  as 
it  enters  the  bladder,  as  these  are  points  of  natural  constriction  of  the  caliber 
of  the  ureter.  The  incision  may  be  made  as  a  muscle-splitting  incision  as  in 
the  McBurney  operation  for  appendicitis,  only  the  muscles  are  split  more 
widely  than  in  the  appendicitis  operation.  When  the  peritoneum  is  reached 
it  is  not  incised  but  is  stripped  up.  This  is  readily  done  with  dry  gauze  on 
a  sponge  forceps,  the  stri^Dping  being  toward  the  midline.  A  long  retractor  is 
inserted  toward  the  midline  and  the  iliac  arteries  are  demonstrated.  The 
ureter  practically  always  adhers  to  the  peritoneum  and  is  recognized  as  a 
band.  If  a  good  light  is  obtainable  and  the  ureter  can  be  watched  for  a  mo- 
ment peristalsis  will  often  be  seen.  The  ureter  may  be  dilated  above  the  stone. 
The  stone  can  frequently  be  felt  and  the  ureter  thereby  is  readily  recognized. 
When  the  peritoneum  has  been  stripped  up  as  far  toward  the  spine  as  can  be 
readily  done  the  ureter  v/ill  be  found  adherent  to  the  peritoneum  and  just 
external  to  the  line  of  attachment  of  the  peritoneum  to  the  spine.  If  the 
pelvic  portion  of  the  ureter  is  to  be  exposed  an  incision  along  the  outer  bor- 
der of  the  rectus  muscle  is  made,  or  a  lower  muscle-splitting  incision.  A  use- 
ful guide  to  the  ureter  is  the  point  at  which  it  crosses  the  iliac  artery  at  the 
bifurcation  of  ^  the  common  iliac. 

After  the  stone  is  located  the  ureter  is  isolated  by  blunt  hooks  or  by 
passing  a  stout  catgut  ligature  around  it  without  tying  the  ligature.  The 
ureter  is  brought  toward  the  wound.  It  should  not  be  dissected  any  freer 
from  the  surrounding  tissues  than  is  necessary  because  this  may  interfere 
with  its  nutrition  and  consequently  delay  healing.  After  protecting  the  sur- 
rounding tissues  with  gauze  packing  a  longitudinal  incision  is  made  over  the 
stone  which  is  extracted.  It  is  best,  as  a  rule,  not  to  attempt  to  suture 
the  ureter,  though  if  the  incision  is  unusually  long  a  few  interrupted  sutures  of 
fine  tanned  or  chromic  catgut  may  be  placed.  They  should  not  penetrate  the 
whole  thickness  of  the  ureteral  wall.  A  cigarette  drain  or  a  strip  of  rubber 
tissue  is  carried  down  to  the  wound  in  the  ureter.  If  the  wound  in  the  ureter 
is  in  the  pelvis  a  soft  rubber  tube  should  never  be  used  for  drainage.  Sev- 
eral cases  are  on  record  where  the  resting  of  a  soft  rubber  tube  on  the  iliac 
artery  unprotected  by  peritoneal  covering  has  produced  secondary  hemor- 
rhage by  pressure  necrosis  in  the  artery.  A  cigarette  drain  or  a  strip 
of  rubber   tissue   will   hardly   cause   this.      In   extraction    of   a   stone    from 


KIDNEY,    URETER,    AND    BLADDER  677 

the  ureter  above  the  ])elvis,  wliere  tlie  drainage  will  not  be  in  contact  with 
any  large  vessels,  a  soft  rnbber  tube  may  be  used. 

Many  ureteral  stones  can  be  removed  with  a  cystoscope  in  the  hands  of  an  ex- 
pert urologist.  If  this  seems  possible  after  the  size  and  location  of  the  stone  have 
been  determined,  an  effort  should  be  made  to  extract  the  stone  in  this  manner  be- 
fore resorting  to  operation.  Only  one  well  trained  in  such  work  should  attempt 
this,  hoAvever,  as  it  requires  much  skill  and  practice. 

The  ureter  is  sometimes  divided  accidentally  in  operations  in  its  neigh- 
borhood, particularly  in  extensive  operations  for  malignant  growths  of  the 
uterus.  If  the  other  kidney  is  sound  the  Mayos  practice  simple  ligation  of 
the  ureter  and  find  that  the  kidney  is  obliterated  with  but  little  or  no  pain 
and  that  the  other  kidney  takes  up  the  work  satisfactorily.  If,  however,  there 
is  any  suspicion  of  the  function  of  the  opposite  kidney,  this  should  not  be 
done.  If  it  is  possible  to  do  so  without  too  great  risk  to  the  patient  an 
effort  should  be  made  to  reestablish  the  continuity  of  the  ureter.  Various 
operations  have  been  devised  for  this  purpose,  but  it  has  been  quite  clearly 
proved,  particularly  by  the  Avork  of  R.  J.  Payne,  of  Norfolk,  Va.,  that  all  of 
the  methods  of  uniting  a  divided  ureter  are  likely  to  be  followed  by  stric- 
ture except  the  simple  eud-to-end  method.  This  is  logical  because  here  the 
minimum  amount  of  raAv  surface  is  apposed  and  consequently  there  is  less 
scar  tissue  to  cause  later  contraction. 

If  a  satisfactory  exposure  can  be  had  the  suturing  together  of  a  divided 
ureter  is  not  a  very  difficult  procedure.  The  sutures  may  be  of  ver}^  fine  silk 
or  preferably  of  fine  tanned  or  chromic  catgut.  The  objection  to  silk  is  that 
it  may  work  into  the  lumen  and  as  a  foreign  body  form  a  nucleus  for  a  stone. 
Three  interrupted  sutures  are  passed  at  equal  distances  around  the  circum- 
ference of  the  ureter  and  approximate  the  divided  ends  of  the  ureter  in 
much  the  same  manner  as  Carrel  uses  in  suturing  blood  vessels.  All  of  these 
sutures  should  be  passed  before  any  of  them  is  tied.  In  this  manner  they 
can  be  simultaneously  draAvn  taut  and  tied  one  at  a  time  Avhile  the  others 
are  held  taut,  so  keeping  unnecessary  strain  from  the  suture  that  is  being 
tied.  The  ends  of  the  sutures  are  left  long,  the  margins  of  the  wound  are 
whipped  over  with  a  continuous  suture  of  fine  tanned  or  chromic  catgut  in 
a  fine  curved  needle  Avhile  holding  the  three  tractor  sutures  in  such  a  manner 
as  to  render  the  part  of  the  wound  that  is  being  sutured  readily  accessible  and 
moderately  tense.  While  suturing  between  two  tractor  sutures  the  third 
should  be  slightly  pulled  away  to  prevent  the  possibility  of  catching  the 
opposite  Avail  of  the  ureter  in  the  sutures.  The  sutures  should  not  be  draAvn 
too  tightly,  but  just  enough  to  secure  accurate  approximation.  After  the 
AAiiole  circumference  of  the  divided  ureter  has  been  sutured,  the  ends  of  the 
tractor  sutures  are  cut  rather  long  and  the  ureter  is  returned  to  its  bed. 

When  a  considerable  portion  of  the  ureter  has  been  sacrificed  it  is 
impossible  to  approximate  the  ends  of  the  ureter  Avithout  too  much  tension. 
As  suggested  by  Payne,  of  Norfolk,  much  can  often  be  gained  by  mobiliz- 
ing  the   kidney   and   its   pelvis   and   the   upper   ureter   through    an   incision 


678  OPERATIVE   SURGERY 

made  as  tlioiigli  a  nephrectomy  were  to  be  done.  The  kidney  and  ureter 
may  be  shoved  down  to  such  an  extent  as  to  overcome  a  considerable  de- 
fect in  the  ureter  and  permit  approximation  of  its  ends  which  would  other- 
wise be  impossible. 

In  a  contemplated  excision  of  the  bladder  or  in  injury  of  the  ureter  near 
the  bladder  a  direct  anastomosis  cannot  be  made  and  here  the  question  of  the 
disposition  of  the  ureter  must  be  settled.  There  is  a  choice  of  four  different 
methods. 

1.  The  ureter  ma^^  be  tied  and,  as  has  already  been  mentioned  the  kidney 
will,  as  a  rule,  eventually  atrophy  and  give  no  further  trouble.  This  method 
may  be  used  in  emergencies  when  the  patient  is  in  shock  or  the  condition  is 
so  grave  as  to  demand  the  quickest  procedure  and  when  there  is  assurance 
that  the  ureter  and  kidney  on  the  other  side  are  normal.  Such  a  method 
should  be  only  exceptionally  resorted  to  as  the  aim  in  surgery  should  be, 
first,  to  preserve  life  and,  second,  to  preserve  function.  It  is  only  when  these 
two  aims  are  in  conflict  that  function  should  be  destroyed. 

2.  The  ureter  may  be  transplanted  to  the  skin  as  originally  proposed 
by  Harrison  and  by  Bottomley.^  Here  the  ureter  is  brought  to  the  skin  of 
the  loin  and  a  special  apparatus  used  to  collect  the  urine.  This  transplan- 
tation can  be  done  either  extraperitoneally  or  transperitoneally,  transplant- 
ing preferably  one  ureter  at  a  time.  Instead  of  doing  this  the  ureter  may 
be  ligated  and  a  nephrostomy  done  according  to  the  method  of  Watson,  using 
a  special  apparatus  to  collect  the  urine  from  the  nephrostomy  wound.  Such 
procedures  may  be  resorted  to  in  patients  that  are  past  forty  years  wdiere 
both  ureters  must  be  transplanted. 

3.  The  ureter  may  be  transplanted  into  the  bowel.  This  may  be  neces- 
sary because  of  the  extensive  disease  of  the  bladder  or  in  exstrophy  of  the 
bladder. 

4.  The  ureter  may  be  transplanted  into  the  bladder.  This,  of  course,  is  the 
most  desirable  disposition  of  the  ureter  but  unfortunately  it  is  not  always  possi- 
ble. In  resection  of  a  portion  of  the  bladder  for  malignant  disease  when  the 
orifice  of  the  ureter  is  involved,  the  ureter  may  be  transplanted  into  the 
bladder  with  considerable  assurance  of  a  permanent  preservation  of  the 
function  of  the  kidney  from  which  the  ureter  comes. 

The  technic  of  this  transplantation  depends  to  some  extent  upon  the 
amount  of  bladder  that  must  be  removed.  The  Coffey  operation  should  be 
used  wherever  possible  in  order  to  prevent  back  pressure  from  the  bladder 
and  to  establish  a  valve  of  the  mucosa.  This  operation  consists  in  making 
an  incision  about  an  inch  long  through  the  serous  and  muscular  coats  of 
the  bladder  and  down  to  the  mucosa.  After  undermining  the  muscular  coat 
on  each,  side  a  small  stab  wound  is  made  through  the  mucosa  at  the  distal 
end  of  the  incision.  The  ureter  is  split  and  caught  near  the  tip  with  a  single 
suture  of  plain  catgut  which  has  a  needle  on  both  ends.  First  one  needle 
and  then  the   other  is  passed  through' the   stab   wound  in   the   mucosa  and 


ijour.   Am.   Med.    Assn.,    1907,    xlix,    141,   et   seq. 


KIDNEY,    URETER,    AND   BLADDER 


679 


penetrates  the  bladder  from  Avitliin  outward  at  a  point  about  three-quarters  of 
an  incli  from  the  stab  Avound.  There  sliould  be  a  short  space  between  the 
points  of  exit  of  the  needles.  The  suture  is  then  gradually  pulled  upon 
until  the  ureter  is  drawn  into  tlie  bladder.  The  ureter  is  fixed  by  tying  this 
suture  and  the  muscular  and  peritoneal  coats  of  the  bladder  are  sutured 
too'other  over  it.  An  additional  stay  suture  of  catgut  fixes  the  ureter  to 
the  bladder  Avail  about  a  (|uarter  of  an  inch  from  the  site  of  the  anastomosis. 
If  it  is  possil)le  to  do  so  it  is  best  to  place  a  second  row  of  sutures  to 
bury  the  first  row,  though  care  must  be  taken  not  to  constrict  the  ureter, 
as  this  Avill  have  the  effect  of  damming  back  the  urine  and  may  produce 
a  hydronephrosis  with  destruction  of  the  kidney,  just  as  Avould  occur  af- 
ter ligation  of  the  ureter.  The  ureter  should  be  handled  as  gently  as  pos- 
sible during  all  of  these  manipulations.  It  should  never  be  clamped  at  the 
end  or  elscAvhere  even  with  a  soft  nose  forceps  and  its  mucosa  should  not 
be  sutured  except  with  the  first  fixation  suture  which  is  of  catgut  and 
passes  through  the  tip  of  the  ureter,  fixing  the  end  of  the  ureter  within 
the  lumen  of  the  bladder.  The  next  fixation  suture  which  is  passed  about 
one-quarter  of  an  inch  from  the  site  of  anastomosis  does  not  penetrate  to 
the  mucosa  of  the  ureter. 

Frequently,  however,  such  an  ideal  technic  cannot  be  carried  out  and 
it  may  be  necessary  to  make  a  direct  transplantation.  Whenever  a  trans- 
plantation is  done  there  should  be  no  tension  at  the  junction  of  the  ureter 
and  bladder  for  this  Avill  surely  imdte  failure.  If  so  much  of  the  bladder 
and  ureter  are  sacrificed,  as  after  an  operation  for  cancer,  that  it  is  im- 
possible to  implant  the  ureter  after  the  method  described  without  tension, 
the  direct  implantation  should  be  done.  Here  the  inch  of  the  ureter  that 
is  imbedded  in  the  bladder  wall  is  not  needed  so  tension  may  be  avoided. 
In  any  instance,  no  more  of  the  ureter  should  be  separated  from  its  bed  than 
is  necessary  for  the  manipulation  because  an  extensive  dissection  Avill  de- 
stroy the  blood  supply  of  the  ureter  and  predispose  to  fistula  formation  or  to 
poor  healing. 

In  direct  transplantation,  after  mobilizing  the  ureter  and  cutting  its  end 
either  obliquely  or  splitting  it,  a  single  mattress  suture  of  linen  is  passed 
through  the  tip  of  the  ureter  and  left  long.  A  uterine  probe  is  introduced 
through  the  urethra,  either  in  man  or  Avoman,  and  the  tip  of  the  probe  is 
pushed  into  the  Avail  of  the  bladder  at  a  point  Avhere  there  Avill  be  least 
tension  betAveen  a  transplanted  ureter  and  the  bladder  Avail.  A  short  stab  in- 
cision is  made  over  the  point  of  the  uterine  probe  and  the  long  ends  of  the  linen 
suture  in  the  ureter  are  fixed  in  a  loop  knot  around  the  end  of  the  uterine 
probe  (Fig.  595).  The  probe  is  then  AvithdraAvn,  leaving  the  suture  protrud- 
ing from  the  the  external  urethral  meatus.  A  catgut  suture  is  passed  through 
part  of  the  Avail  of  the  ureter  about  one-half  an  inch  from  its  end.  The  linen 
tractor  suture  is  pulled  upon  until  the  ureter  is  draAvn  into  the  bladder  and 
the  catgut  suture  is  flush  Avith  the  external  surface  of  the  bladder  Avail, 
when  the  catgut  suture  takes  a  bite  in  the  bladder  and  is  tied.    A  similar  suture 


680 


OPERATIVE    SURGERY 


is  inserted  on  the  opposite  side  of  the  ureter,  cateliing  only  the  muscular  coat, 
and  further  fixes  the  ureter  to  the  bladder  wall.  Several  other  sutures  are  placed 
still  further  to  invaginate  the  ureter.  If  it  is  possible  to  do  so  the  ureter  is  best 
implanted  into  a  portion  of  the  bladder  that  is  covered  with  peritoneum,  or 
sometimes  a  strip  of  peritoneum  can  be  left  on  the  anterior  surface  of  the  ure- 
ter which  will  greatly  facilitate  the  healing.  Slight  traction  is  made  on  the 
linen  tractor  suture  to  determine  accuratelv  the  amount  of  tension  that  will 


Fig.   595. — A  method  of  transplanting  the   ureter.     A  probe   has   been   thrust  through   the   bladder  wall   and 
the  suture  on  the  end  of  the  prepared  ureter  is   fastened  to  the  tip  of  the  probe. 


be  needed  to  keep  the  ureter  in  position.  When  this  is  established  the  tractor 
suture  is  fastened  to  the  vulva  in  the  female  or  attached  to  a  thin  rubber  band 
and  fastened  to  the  leg  of  the  patient  in  a  male  (Fig.  596).  If  too  much  traction 
is  used  the  suture  quickly  cuts  out  and  if  too  little  is  made  there  is  not  sufficient 
relief  of  whatever  tension  exists  between  the  ureter  and  bladder  at  the  point  of 
junction.  Therefore,  it  is  important  to  determine  this  point  when  the  anastomosis 
has  been  finished  and  before  the  wound  is  closed.  The  dissected  portion  of  the  ure- 
ter is  covered  with  a  peritoneal  flap  (Fig.  596)  or  with  the  sigmoid.     A  small 


KIDNEY,    URETER,    AND    BLADDER 


681 


piece  oL'  rubber  clam  is  carried  clown  to  the  site  of  the  anastomosis  to  conduct  away 
any  urine  if  there  is  lealaige.  All  sutures  that  involve  the  bladder  mu- 
cosa should  be  of  ]>lain  catgut  and  olliers  in  the  bladder  wall  may  be 
of  fine  tanned  or  cliromic  catgut.  The  tractor  suture  of  linen  will  come 
away  in  five  or  six  days  and  in  this  time  union  will  be  sufficiently  firm 
for  ]io  leakage  to  occur,  particularly  if  peritoneum  can  be  utilized  either 
on   the   anterior   surface   of   the   ureter   or   on   the   bladder   wall.      The    blacl- 


^'^'   ^^^^'^^^  ureter  has  been  drawn  into   the  bladder  by  the  method  shown  in  the  preceding  illustration, 
ilie  peritoneum  has  been  dissected  so  as  to   form  a  flap  and  completely   envelops  the   ureter. 

der   is   drained   either   by   an   indwelling   catheter   in   the   female,    or   by    a 
perineal  or  suprapubic  cystotomy  in  the  male. 

It  may  be  necessary  to  transplant  both  ureters  into  the  bowel  in  exstrophy 
of  the  bladder  or  where  a  malignant  growth  involves  so  much  of  the  bladder 
wall  as  to  render  a  radical  operation  impossible  or  to  necessitate  removal  of 
the  wdiole  bladder.  In  exstrophy  of  the  bladder,  the  operation  should  not 
be  done  until  the  child  is  about  four  years  old  when  he  can  attend  to  the 


682  OPERATIVE    SURGERY 

emptying  of  the  bowels  at  sutHcient  intervals  to  prevent  too  great  an  accu- 
mulation of  urine  in  the  colon.  In  operation  for  exstrophy  many  plastic  pi'oce- 
dures  have  been  advised,  such  as  turning  in  skin  flaps  from  the  margin 
of  the  ectopic  bladder  and  reconstructing  a  urethra.  Such  operations,  even 
if  successful,  do  not  give  control  of  the  urine,  which  is  the  most  desirable 
thing  to  be  attained.  Besides,  turning  in  flaps  from  the  margins  of  the 
bladder  necessitates  the  turning  in  of  some  portion  of  the  skin  in  Avhich 
hair  will  later  form,  and  this  becomes  a  perpetual  source  of  inflammation 
and  a  nucleus  for  stone  formation. 

Plastic  operations  for  exstrophy  of  the  bladder,  then,  seem  to  accom- 
plish very  little.  The  operation  of  Maydl  consisted  of  dissecting  out  that 
portion  of  the  base  of  the  bladder  containing  the  ureters  and  transplanting 
this  segment  into  the  rectum  as  a  transperitoneal  operation.  In  this  manner 
the  natural  valves  of  the  ureters  are  preserved  but  the  terminal  nerve  sup- 
ply is,  of  course,  destroyed.  Moynihan  has  slightly  modifled  the  Maydl 
operation  by  taking  a  large  portion  of  the  bladder.  Operations  after  the 
Maydl  principle  have  been  followed  by  a  large  mortality.  The  injury  to  the 
nerve  supply  of  the  lower  portion  of  the  ureters  and  the  necessarily  poor  blood 
supply  to  the  transplanted  segment  of  bladder  which,  of  course,  demands  more 
blood  the  larger  the  segment  that  is  transplanted,  are  probably  responsible 
for  the  unsatisfactory  results.  Then,  too,  the  transplantation  of  both  ureters 
at  the  same  operation  greatly  increases  the  danger.  As  pointed  out  by  C.  H. 
Mayo  a  considerable  portion  of  the  urine  is  carried  to  the  right  side  of  the 
colon  as  after  the  Murphy  drip  and  is  here  absorbed.  If  both  ureters  are 
transplanted  at  the  same  time  uremia  may  result,  but  if  there  is  an  interval 
of  two  weeks  or  more  between  the  transplantations,  the  patient  will  have 
developed  sufficient  protective  reaction  against  the  unphysiologic  disposi- 
tion of  the  urine  to  withstand  the  result  of  the  second  transplantation.  This 
is  shown  by  the  fact  that  C.  H.  Mayo^  reports  that  since  1896  six  patients 
with  exstrophy  of  the  bladder  have  been  operated  upon  by  plastic  methods 
and  none  has  control  of  the  urine ;  three  were  operated  upon  by  the  Maydl- 
Moynihan  method  and  two  of  these  died  in  the  hospital  from  uremia;  while 
thirteen  patients  were  successfully  operated  upon  by  the  transplantation  of 
the  ureters  wdth  only  one  operative  death.  These  statistics  point  clearly  to  the 
wisdom  of  transplantation  of  the  ureter  into  the  sigmoid  at  separate  sit- 
tings as  the  operation  of  choice  in  exstrophy  of  the  bladder.  Exactly  the 
same  technic,  of  course,  could  be  used  when  malignant  disease  of  the  bladder 
is  so  extensive  as  to  necessitate  the  transplantation  of  the  ureters  elsewhere, 
though  Avith  the  ditference  that  in  the  young  the  transplantation  into  the 
sigmoid  is  the  most  satisfactory  method,  Avhereas  in  the  elderly  it  may  be 
safer  to  bring  the  opening  of  the  ureters  to  the  skin  in  the  loin  as  practiced 
by  Bottomley  or  to  use  the   double  nephrostomy  of  Watson.     The   indica- 


=Mayo,   C.   H.:   Jour.  Am.   Med.   Assn.,   1917,  Ixix,   2079,   et  seq. 


KIDNEY,    URETER,    AND    BLADDER  683 

tions  for  tlio  dinVreiit  ])ro('(Mlur(',s  clei)0jul  to  some  extent  upon  the  desire  of 
the  patient. 

If  the  ureter  is  to  be  transphinted  into  the  sigmoid  either  for  exstrophy 
of  the  hhidder  or  for  malignancy,  the  first  operation  is  best  done  on  the 
right  side,  making  an  incision  slightly  to  the  right  of  the  midline,  because 
the  sigmoid  is  on  the  left  and,  as  pointed  out  by  C.  H.  Mayo,  if  the  operation 
on  the  left  side  is  first  done  it  may  be  more  difficult  to  mobilize  the  sigmoid 
in  the  second  operation  which  must  be  on  the  right  side.  After  exposing 
the  sigmoid  and  determining  the  point  at  which  the  anastomosis  should 
be  made,  and  particularly  with  regard  to  a  subsequent  operation  on  the  left 
side,  this  point  is  fixed  by  clamping  the  sigmoid  with  a  large  curved  intes- 
tinal clamp.  The  lower  end  of  the  ureter  is  dissected  out  and  divided  close 
to  the  bladder  and  the  proximal  end  is  split  for  a  quarter  of  an  inch. 
In  order  to  preserve  the  nutrition  of  the  ureter,  as  in  operations  for  trans- 
plantation of  the  ureter  into  the  bladder,  no  more  of  the  ureter  is  dissected 
free  than  is  necessary  for  the  purposes  of  the  operation.  The  distal  end  of  the 
ureter  is  tied  and  in  exstrophy  it  may  be  buried  in  the  tissues  around  it 
by  a  few  catgut  sutures.  The  peritoneum  and  muscular  coats  of  that  portion 
of  the  sigmoid  in  the  grasp  of  the  curved  intestinal  clamp  is  incised  for  about 
an  inch  and  a  half.  It  is  best  to  make  this  incision  through  the  firm  longi- 
tudinal bands  in  the  Avail  of  the  sigmoid.  The  incision  is  carried  down  to 
the  mucosa  but  not  through  it.  At  the  distal  portion  of  the  incision  the 
mucosa  is  punctured  and  a  fine  tanned  catgut  suture  which  transfixes  the  tip 
of  the  ureter  is  threaded  with  a  needle  at  each  end,  carried  through  this 
punctured  wound  in  the  mucosa,  and  penetrates  the  bowel  half  an  inch 
distal  to  the  punctured  wound.  Both  needles  are  carried  through  a  short 
distance  from  each  other  and  the  suture  is  tied,  so  fixing  the  ureter  in 
its  new  position.  The  wall  of  the  ureter  is  caught  in  the  bite  of  a  catgut 
suture  just  as  it  penetrates  the  mucosa  and  the  suture  also  catches  a  bite 
in  the  muscular  and  peritoneal  coats  of  the  sigmoid  on  each  side.  This  suture 
is  tied  so  as  still  further  to  fix  the  ureter  in  the  wall  of  the  sigmoid.  The 
incision  is  closed  by  continuous  sutures  of  tanned  or  chromic  catgut  which 
bury  the  ureter  on  the  mucosa.  A  valve  is  formed  of  the  mucosa  which  pre- 
vents back  pressure.  This  method  of  Coffey  tends  greatly  to  diminish  as- 
cending infection  of  the  kidney.  By  using  this  principle  of  his,  pressure 
within  the  bowel  produces  a  valve-like  effect  on  the  mucosa  and  occludes 
the  end  of  the  ureter  against  the  gas  pressure  within  the  bowel,  but  at  the  same 
time  does  not  produce  sufficient  pressure  to  prevent  delivery  of  the  urine  into 
the  bowel.  The  wound  is  closed  without  drainage,  or  else  with  a  small  soft 
tube  of  rubber  dam.  The  sphincter  is  dilated  and  a  tube  inserted  a  few 
inches  in  the  rectum  for  the  first  four  or  five  days  in  order  to  facilitate 
the  emptying  of  the  urine  until  the  bowel  gradually  becomes  accustomed  to 
it.  The  second  ureter  is  transplanted  about  two  weeks  later  if  the  patient 
is  in  good  condition. 


684  OPERATIVE    SURGERY 


THE  BLADDER 


Tumors  of  the  bladder  may  require  operation.  Many  tumors,  particu- 
larly the  benign  papillomas,  are  cured  by  fulguration,  and  radium  in  some 
cases  IS  beneficial.  If  the  tumor  is  malignant  and  involves  a  considerable 
portion  of  the  bladder  wall,  and  particularly  if  it  does  not  readily  respond 
to  fulguration  or  radium,  operation  is  the  best  method  of  treatment.  If  the 
growth  has  a  distinct  pedicle  the  mucosa  can  be  excised  around  the  pedicle 
Avith  a  cautery  but  usually  the  resection  should  include  the  whole  thickness 
of  the  bladder  wall,  going  some  distance  beyond  the  apparent  margins  of  the 
growth  into  what  seems  to  be  healthy  tissue.  Excision  of  the  total  thickness 
of  the  bladder  wall  is  no  more  difficult  than  excision  of  a  portion  of  the 
wall  and  is  more  likely  to  result  in  cure.  If  the  growth  involves  the  part  of 
the  bladder  that  is  covered  with  peritoneum  the  peritoneal  cavity  is  opened 
and  packed  off  and  the  diseased  section  is  removed.  If,  however,  other 
portions  of  the  bladder  are  involved,  the  operation  should  be  done  ex- 
traperitoneally  if  possible.  Most  tumors  of  the  bladder  originate  in  the  base 
of  the  bladder  and  many  of  these  involve  one  of  the  ureteral  openings, 
so  that  excision  of  this  section  of  the  bladder  will  involve  transplanta- 
tion of  the  ureter,  or  else  ligation  of  the  ureter  if  the  remaining  kidney  is 
healthy  and  it  is  impossible  to  transplant  the  ureter.  Occasionally,  both 
ureters  require  transplantation. 

Whether  the  peritoneal  cavity  is  opened  or  not  the  patient  is  placed  in 
the  Trendelenburg  position  and  good  exposure  is  obtained  by  a  large  incis- 
ion in  the  bladder.  Care  is  always  taken  to  protect  the  prevesical  space 
by  packing  it  with  gauze.  The  incision  is  preferably  made  transversely,  though 
the  location  of  the  disease  will  control  its  direction.  The  excision  of  the 
bladder  w^all  is  made  with  an  electric  cautery  wherever  possible.  The  blad- 
der wound  is  closed  with  two  layers  of  catgut  sutures,  the  inner  layer 
of  plain  catgut  and  catching  as  little  as  possible  of  the  mucosa.  The  outer 
layer  of  tanned  or  chromic  catgut  is  inserted  through  the  muscular  coat 
only  and  like  the  inner  layer  is  a  continuous  suture.  Drainage  is  always 
placed  either  through  a  portion  of  the  incision,  preferably  as  close  to  the 
peritoneal  fold  as  possible,  or  the  incision  may  be  closed  completely  and 
drainage  instituted  through  a  stab  wound  at  about  the  apex  of  the  bladder 
and  an  inch  or  more  from  the  sutured  incision.  If  it  is  necessary  to  dissect 
the  space  of  Retzius  extensively,  a  gauze  cigarette  drain  is  placed  to  the 
bottom  of  this  space  in  addition  to  the  drainage  in  the  bladder. 

Diverticula  of  the  bladder  are  treated  satisfactorily  by  operation.  The 
diverticulum  s}iould  be  accurately  located  by  roentgen  rays  and  by  cysto- 
scopic  examination  before  the  operation  is  attempted.  The  bladder  is  opened 
suprapubically  and  the  diverticulum  explored  with  the  finger  and  by  inspection 
with  the  patient  in  the  Trendelenburg  position.  If  the  pouch  is  not  very  ad- 
herent it  may  be  pulled  into  the  bladder  with  forceps,  or,  using  the  technic 
of  H.  H.  Young,  it  may  be  everted  by  a  suction  apparatus  that  is  attached 


KIDNEY,    URETER,    AND    BLADDER  685 

to  a  large  tiil)e  M'liieli  is  placed  over  the  neck  of  the  divei-ticulum.  Small  non- 
adherent diverticula  are  treated  satisfactorily  in  this  way.  When  the  diver- 
ticulum is  large  or  when  it  is  adherent  it  is  necessary  to  dissect  it  externally. 
After  opening  the  bladder  M'idely  through  the  prevesical  space  and  pro- 
tecting the  prevesical  space  with  gauze  packing,  the  diverticulum  is  ex- 
plored with  the  finger.  It  may  be  packed  with  gauze  to  identify  it,  as  sug- 
gested by  Lower,  or  with  one  or  two  fingers  in  the  diverticulum,  as  practiced 
by  Judd,  dissection  is  carried  through  the  prevesical  tissues  to  the  sac  which 
is  lifted  up  by  the  fingers  within  it.  If  the  sac  is  covered  by  peritoneum  the 
peritoneum  may  be  opened  though  usually  this  is  not  necessary.  The  vas 
deferens  and  the  ureter  must  be  identified  and  injury  to  these  structures 
avoided.  Occasionally  the  ureter  is  involved  in  the  diverticulum  and  it  may  be 
necessary  to  divide  it  and  reimplant  it  into  the  bladder.  If  the  prostate  is  en- 
larged it  should  be  removed  at  the  same  operation.  When  the  sac  has  been  com- 
pletely freed  the  internal  relation  of  the  neck  of  the  sac  to  the  ureter  is  noted  and 
the  diverticulum  is  then  cut  away.  The  opening  in  the  bladder  is  closed  as  after 
operations  for  tumors.  The  suprapubic  opening  is  sutured  except  for  a  drainage 
tube  which  comes  out  at  the  upper  part  of  the  bladder  wound  near  the  peritoneal 
fold.  A  cigarette  drain  is  carried  down  through  the  prevesical  space  to  the 
site  of  the  old  diverticulum. 

Approach  to  the  bladder  for  the  operations  that  have  been  mentioned,  or 
for  stone  or  for  drainage  is  frequently  indicated.  This  operation  of  supra- 
pubic cystotomy  may  be  exceedingly  simple  when  the  bladder  is  distended 
or  capable  of  being  distended,  or  it  may  be  difficult  if  the  bladder  is  thick 
and  contracted.  Where  it  is  possible  to  do  so  it  is  best  to  distend  the  bladder 
with  some  mild  antiseptic  solution,  such  as  boric  acid  solution,  just  before 
the  operation.  A  soft  rubber  catheter  is  inserted  into  the  bladder  and  the 
warm  boric  acid  solution  is  gradually  introduced  by  gravity  until  the  bladder 
is  filled.  If  the  irrigating  can  is  not  more  than  two  feet  above  the  level 
of  the  patient's  body  it  is  hardly  possible  for  the  bladder  to  be  damaged  by 
the  irrigation.  The  catheter  is  left  in  position.  The  bladder  should  never  be 
filled  by  a  piston  syringe,  as  several  cases  are  recorded  in  which  an  appar- 
ently low  degree  of  pressure  with  such  a  syringe  ruptured  the  bladder.  If 
gravity  is  used  slowly  and  carefully  such  an  accident  is  impossible.  It  must 
be  borne  in  mind,  however,  that  in  manipulating  a  well  filled  bladder  strong 
pressure  upon  it  may  cause  it  to  rupture.  A  tape  is  tied  around  the  penis 
in  order  to  prevent  the  escape  of  the  fluid  around  the  catheter.  An  incision  is 
made  in  the  abdominal  wall,  usually  a  longitudinal  incision,  and  after  separating 
the  fibers  of  the  recti  and  pyramidalis  muscles  the  fascia  immediately  beneath 
them  is  incised  and  the  prevesical  fat  exposed.  The  peritoneal  fold  in  the  upper 
portion  of  the  wound  is  recognized  and  gently  stripped  upward  with  gauze.  If  it 
is  opened  it  may  be  immediately  sutured  without  danger.  The  fat  is  divided 
down  to  the  anterior  wall  of  the  bladder  and  is  then  pushed  to  the  side  and  down- 
ward into  the  space  of  Retzius,    It  is  well  to  place  a  small  gauze  pack  at  the 


686  OPERATIVE   SURGERY 

Tipper  angle  of  the  wound  in  order  to  protect  tlie  peritoneal  cavity  from  being 
accidentally  opened  while  enlarging  tlie  incision.  If  the  operation  is  done 
merely  for  drainage  and  exploration  a  short  vertical  incision  that  will  admit 
the  finger  is  all  that  is  necessary,  but  if  a  large  tumor  is  to  be  removed  a 
more  ample  exposure  is  required.  Here  the  incision  in  the  bladder  wall 
should  be  transverse,  keeping  along  its  apex  and  as  close  to  the  peritoneal 
fold  as  seems  safe.  If  it  goes  down  into  the  space  of  Eetzius  and  near  the 
urethral  opening  it  is  difficult  to  suture  and  to  heal.  The  bladder  wall  having 
been  recognized  may  be  fixed  either  by  two  Allis  forceps  or  by  two  sutures  of 
catgut  or  silk  that  are  inserted  with  a  round  curved  needle.  The  fluid  is  then 
drawn  off  through  the  catheter  in  the  urethra  and  the  bladder  is  incised 
between  the  two  forceps  or  sutures.  In  this  way  the  prevesical  tissues  are  not 
flooded  with  the  vesical  contents  and  infection  is  less  likely  to  occur.  Where 
the  bladder  is  distended  from  an  impermeable  obstruction,  the  urine  may  be 
drawn  off  by  thrusting  a  trocar  and  cannula  through  the  bladder  wall  -which 
is  incised  after  withdrawing  the  trocar  and  cannula.  It  may  occasionally  be 
difficult  to  recognize  the  bladder  wall  if  not  distended,  but  when  filled  with 
fluid  it  is  easih'  identified.  After  opening  the  bladder  the  incision  is  extended 
for  better  exposure  or  the  stone  is  extracted,  or  drainage  instituted,  according 
to  the  indications.  The  bladder  should  always  be  explored  thoroughly  with  the 
finger  before  drainage  is  placed.  If  the  incision  in  the  bladder  wall  is  short  a 
drainage  tube  is  brought  out  at  the  upper  portion  of  the  incision  and  the  lower 
margin  of  the  wound  is  closed  with  catgut  sutures.  These  sutures  in  a  short 
w^ound  are  interrupted,  of  tanned  catgut,  and  take  either  none  of  the  mucosa  or 
as  small  an  amount  of  it  as  possible.  In  a  larger  bladder  wound  the  two  layers 
of  sutures  that  have  been  mentioned  are  the  best  method  of  closing  the  wound. 
Bleeding  in  the  bladder  wound  is  controlled  by  whipping  over  the  bleeding 
spot  Avith  small  plain  catgut  in  a  round  noncutting  needle. 

Occasionally,  drainage  is  done  through  the  perineum  and  the  supra- 
pubic wound  is  closed  entirely.  With  the  patient  in  the  dorsal  position 
pedicle  forceps  or  long  dressing  forceps  are  inserted  into  the  bladder  and 
through  the  internal  meatus  into  the  urethra.  Pressure  is  made  on  the  for- 
ceps so  that  the  tip  bulges  in  the  perineum  and  is  cut  down  upon  in  the  peri- 
neum. A  rubber  drainage  tube  or  a  large  soft  rubber  catheter  is  grasped 
with  the  forceps,  drawn  through  into  the  bladder,  and  fixed  to  the  skin  of 
the  perineum  with  a  silkworm-gut  suture.  The  end  of  the  catheter  should  not 
be  more  than  two  inches  within  the  bladder  as  otherwise  it  will  cause  an 
unnecessary  amount  of  irritation.  The  suprapubic  wound  in  the  bladder 
may  then  be  entirely  closed. 

If  a  suprapubic  cystotomy  is  done  with  the  bladder  collapsed  the  abdom- 
inal incision  is  the  same  as  when  the  bladder  is  distended,  but  the  vesical  wall 
is  much  more  inaccessible.  Having  the  patient  in  the  Trendelenburg  posi- 
tion is  a  great  help.  Dissection  is  carried  down  to  the  pubic  bone  and 
then  the  prevesical  fat  is  cut  through  until  the  bladder  is  demonstrated. 
After   it   has   been  recognized   it  is   incised   and   the    operation   finished   in 


KIDNEY,    URETER,    AND   BLADDER  687 

the  usual  maiiiuM-.  If  a  sound  or  a  callietiT  can  he  inlroduccd  into  the  l)lad- 
der  usually  it  can  l)c  dislcndcd,  but  careful  dissection  without  a  sound  will, 
as  a  rule,  expose  the  bladder  wall  Avithout  much  difficulty. 

With  an  iini)ernieal)le  stricture  or  a  prostatic  obstruction  it  is  sometimes 
impossible  to  enter  the  bladder  with  an  instrument  through  the  urethra. 
These  patients  are  often  poor  surgical  risks  and  it  is  necessary  to  evacuate 
the  urine  by  as  simple  a  process  as  possible.  Here  a  puncture  with  a  tro- 
car and  cannula  is  satisfactory.  A  trocar  and  cannula  are  selected  so  that 
the  trocar  can  be  removed  and  a  small  soft  rubber  catheter  threaded  through 
the  cannula  into  the  bladder.  The  trocar  and  cannula  should  be  of  such  a 
type  that  the  urine  can  be  drawn  off  through  a  lateral  projection  near  the 
end  of  the  cannula.  Before  the  operation  the  catheter  is  tested  to  see  that 
it  will  go  through  the  cannula  easily.  The  skin  of  the  abdomen  is  infiltrated 
and  an  incision  of  half  an  inch  is  made  just  above  the  pubis  and  close  to  the 
pubic  bone.  The  deeper  tissues  are  infiltrated  with  procaine  solution,  a  proper 
trocar  and  cannula  are  grasped  firmly,  and  thrust  quickly  into  the  bladder 
in  a  direction  inward  and  upw^ard.  Of  course  this  is  never  done  except 
Avlien  the  bladder  is  fully  distended.  If  the  trocar  and  cannula  go  straight 
inward  the  prevesical  space  may  be  injured,  the  trocar  will  sometimes  cut 
the  bladder  wall  obliquely  and  if  there  is  a  large  prostate  it  may  not  en- 
ter the  bladder  at  all.  By  directing  the  thrust  upward  as  well  as  inward 
this  accident  to  the  prevesical  space  is  avoided  and  there  is  no  danger  of 
injuring  the  peritoneum  if  the  bladder  is  distended,  provided  the  entrance 
point  in  the  abdominal  w^all  is  just  above  the  pubic  bone.  The  trocar 
is  pulled  back  and  the  urine  allowed  to  flow.  After  the  bladder  has  been 
emptied  the  trocar  is  unscrewed,  the  cannula  being  left  in  position.  The 
cannula  must  be  kept  well  within  the  bladder  wall,  because  if  it  is  once 
withdrawn  after  the  bladder  has  been  emptied  it  will  not  only  be  impossible 
to  reinsert  it  but  leakage  will  certainly  occur  into  the  prevesical  space. 
The  previously  selected  soft  rubber  catheter  with  an  additional  eye  cut  near 
the  end  is  threaded  through  the  cannula  w^hich  is  then  withdrawn. 

The  amount  of  catheter  to  be  left  in  the  bladder  is  determined  by  compar- 
ing it  with  another  catheter  of  equal  length.  There  should  be  four  inches  of 
it  below  the  level  of  the  skin  and  if  the  patient  is  stout  five  inches  w^ould 
be  better.  It  is  wrapped  around  with  adhesive  at  the  skin  level  and  fastened 
in  position  by  a  suture  of  silkworm-gut  which  goes  through  the  skin  and 
through  the  adhesive  that  is  wrapped  around  the  catheter  but  does  not 
penetrate  the  wall  of  the  catheter  itself.  The  catheter  should  be  new  and 
should  be  tested  before  it  is  used.  An  old  one  will  sometimes  break  and 
may  leave  a  portion  of  it  in  the  bladder. 

This  method  of  drainage  will  not  cause  leakage  around  the  catheter  and 
the  patient  can  be  kept  perfectly  dry.  The  catheter  must  not  be  removed, 
however,  for  at  least  two  weeks  unless  as  a  preliminary  step  to  an  operation, 
because  it  takes  about  this  time  for  the  granulations  to  produce  firm  tissue 
around   its   wall   and   so    prevent   infiltration    of   urine    into    the    prevesical 


688  OPERATIVE    SURGERY 

siDaee.  If  the  catheter  has  Ijecome  aeeideiitally  displaced  in  the  first  few 
days  after  such  an  operation  and  cannot  be  readily  reintroduced,  a  supra- 
pubic cystotomy  should  be  done  at  once  to  protect  the  prevesical  space  from 
infiltration  of   urine. 

Total  excision  of  the  bladder  may  sometimes  be  indicated.  The  first 
stage  consists  of  an  anastomosis  of  the  ureters  to  the  sigmoid,  or  bringing 
them  to  the  skin  of  the  groin,  or  establishing  the  bilateral  nephrostomy  of 
Watson.  Some  weeks  after  this  has  been  done  the  bladder  is  excised  as  though 
it  were  a  cystic  tumor.  The  anterior  surface  of  the  bladder  is  exposed  through 
an  ample  incision  and  separated  from  the  peritoneum  anteriorly  and  laterally. 
It  is  gradually  delivered  into  the  wound  and  the  dissection  continued  until 
the  neck  of  the  bladder,  the  inferior  vesical  arteries,  and  the  stumps  of 
the  ureters  have  been  reached.  The  vessels  are  doubly  clamped  and  the  base 
of  the  bladder  is  separated  from  the  rectum  as  far  as  possible.  The  neck  of 
the  bladder  is  divided,  preferably  with  the  cautery,  while  making  traction 
to  pull  up  as  much  of  the  urethra  as  possible.  Such  an  operation  is  rarely 
indicated. 

Perineal  section  is  not  done  as  frequently  as  in  preantiseptic  days,  but 
is  occasionally  indicated  particularly  for  deep  stricture.  If  a  grooved 
sound  can  be  passed  into  the  bladder  the  patient  is  placed  in  the  dorsal  posi- 
tion and  an  incision  is  made  in  the  perineum  just  back  of  the  scrotum  down 
to  the  urethra,  which  is  opened.  This  incision  can  be  carried  to  an  inch 
of  the  anus  if  kept  in  the  midline.  The  urethral  bulb  must  not  be  injured 
and  is  pulled  forward  in  the  midline  so  that  the  urethra  is  opened  on  the 
grooved  staff"  and  freely  incised  to  the  apex  of  the  prostate.  The  staff  is 
remoA'-ed  and  a  grooved  director  or  Teale's  gorget,  is  inserted  and  the 
finger  is  pushed  into  the  bladder  with  a  boring  motion  along  the  direc- 
tor or  gorget.  A  drainage  tube  is  inserted.  A  soft  rubber  rectal  tube  does 
well  for  this  purpose.  It  should  be  so  placed  as  not  to  project  into  the 
bladder  more  than  an  inch.  It  is  fixed  in  position  by  suturing  it  to  the 
skin  with  an  interrupted  silkworm-gut  stitch.  Bleeding  is  controlled  by 
whipping  over  the  bleeding  points  with  catgut  in  a  needle  before  inserting 
the  drainage  tube  and  by  iodoform  gauze  packing  around  the  tube  down  to 
the  urethra.  If  there  is  but  little  infection  in  the  bladder  and  the  operation 
IS  done  for  stone  or  for  exploratory  purposes,  the  tube  may  be  removed  in 
three  days.  In  cj'stitis,  drainage  must  be  kept  up  for  several  weeks.  "When 
necessary  to  gain  greater  room  the  incision  may  be  continued  into  the  prostatic 
portion  of  the  urethra  along  the  midline. 

When  it  is  impossible  to  introduce  a  sound  or  staff  into  the  bladder,  ex- 
ternal urethrotomy  becomes  more  difficult.  A  sound  is  introduced  down  to  the 
point  of  obstruction,  which  is  usualh'  in  the  membranous  urethra.  The  in- 
cision is  carefully  carried  down  to  the  sound  and  the  bleeding  is  controlled 
by  clamping  or  by  whipping  over  the  bleeding  points  with  plain  catgut.  The 
urethra  is  incised  as  far  as  the  obstruction.  Sometimes  a  view  of  the  stric- 
ture can  be  obtained  and  a  probe  or  bougie  accurately  introduced  through  the 


KIDNEY,    URETER,    AND    1!I. ADDER  689 

stricl  iiri".  It'  ;i  sluirp-pniiilcd  liciiioslat  ran  Ix'  iiil  I'dduccd  tlio  jaws  are  spread 
aparl  and  Ihc  si  ricliirc  is  dilated.  A  pair  (if  larger  forceps  is  then  inserted  and 
tlie  jaws  are  sjiread.  When  tlie  stricture  is  very  dense  or  wlieii  tliere  is  a  consid- 
erable amount  of  intlaniniatioii  it  may  be  divided  by  au  incision  with  a  knife. 
Vvvy  dense  strictures  luive  l)een  excised  and  efforts  have  1)een  made  to  ap- 
proximate tlu^  ends  of  the  urethra.  This,  however,  is  tedious  and  recurrence 
is  freciuent,  though  wliere  there  is  a  local  heavy  deposit  of  scar  tissue  ex- 
cision nuiy  be  attempted. 

]f  the  opening  in  the  stricture  cannot  be  inspected  a  filiform  bougie 
is  introduced  through  the  urethral  wound.  This  Avill  serve  as  a  guide  for 
the  introduction  of  a  large  instrument  or  a  pair  of  sharp  nose  forceps,  or  a 
knife  to  divide  the  stricture.  The  stricture  is  thoroughly  divided  so  that 
the  finger  can  be  introduced  into  the  bladder.  A  large  soft  rubber  catheter 
or  a  small  rectal  tube  is  carried  into  the  bladder  and  held  in  position  by  su- 
turing it  to  the  skin.  This  should  be  removed  in  three  or  four  days,  the  tube 
boiled,  and  reinserted.  The  wound  is  irrigated  several  times  a  day  with 
hot  boric  acid  solution.  The  patient  is  given  hexamethylenamin  if  the  kidneys 
are  in  a  condition  to  stand  it  without  tf»o  much  irritation  and  every  effort  is 
made  to  prevent  infection. 

Occasionally  after  a  rupture  of  the  urethra  it  is  impossible  to  enter  the 
bladder  from  below.  Here  a  small  suprapubic  incision  is  made  and  the 
urethra  catheterized  or  a  sound  introduced  into  the  urethra  from  within  the 
bladder.  This  will  demonstrate  the  location  of  the  urethra  in  the  perineal 
wound  and  is  a  much  safer  procedure  than  a  prolonged  blind  dissection 
in  the  perineum. 


CHAPTER  XXIX 

OPERATIONS  ON  THE  PROSTATE  GLAND,  THE  TESTICLES  AND  TlHE 

PENIS 

Prostatectomy  may  be  done  by  tlie  perineal  or  the  suprapubic  route. 
There  are  ardent  advocates  of  both  routes  though  the  suprapubic  has  be- 
come more  popular.  The  operation  of  H.  H.  Young  is  probably  the  most 
satisfactory  for  removal  of  the  prostate  through  the  perineum.  The  supra- 
pubic method  is  simpler  and  the  enucleation  following  the  general  principles  of 
the  technic  of  Squiers  has  given  excellent  results. 

The  operator  should  have  the  technic  of  either  route  at  his  command.  In 
the  small  fibrous  prostate,  especially  if  there  is  a  possibility  of  malignancy, 
the  perineal  route  is  preferable.  In  the  large  adenomatous  prostate,  removal 
by  the  suprapubic  route  seems  better.  The  objections  to  the  perineal  route 
are: 

1.  It  is  more  complicated  and  the  operation  takes  somewhat  longer  to 
perform. 

2.  There  is  a  possibility  of  injury  to  the  rectum  and  fistula  formation. 

3.  It  is  somewhat  more  difficult  to  control  the  bleeding  by  the  perineal 
route. 

4.  Persistent  urinary  fistula  is  probably  more  frequent  by  the  perineal 
route. 

The  objections  to  the  suprapubic  route  are: 

1.  The  removal  of  the  whole  urethra  contained  in  the  prostate  is  some- 
times folloAved  by  stricture. 

2.  If  the  prostate  is  cancerous  and  very  adherent  it  can  be  removed  more 
satisfactorily  by  sharp  dissection  through  the  jDerineal  route  than  through 
the  suprapubic. 

3.  It  is  claimed  by  some  operators  that  on  account  of  the  extensive 
manipulation  within  the  bladder  by  the  suprapubic  route  uremia  is  more 
likely  to  result. 

The  choice  of  these  two  routes  depends  somewhat  upon  the  experience 
of  the  surgeon.  The  operation,  particularly  the  suprapubic  operation,  is 
technically  not  very  difficult,  though  it  is  particularly  necessary  to  have  had 
training  in  assisting  and  observing  these  operations  done  bj'  one  who  is  skilled 
in  this  work  before  the  surgeon  attempts  the  operation. 

It  is  most  important  to  have  the  patient  in  the  proper  condition  to  stand 
the  operation.  The  high  mortality  for  prostatectomy  in  the  early  history 
of  this  operation  was  partly  due  to  a  crude  technic  but  more  to  the  inability 
to  determine  the  functional  capacity  of  the  kidneys.     "When  there  is  much 

690 


PROSTATE,    TESTICLES,    AND   PENIS  691 

residual  ui'iiic  1l)r  l)ii('k  ])Tessure  ii])()ii  tln'  kidneys  gradually  alters  the  con- 
ditions iiiidrr  wliit'li  tliey  finu'tiou  and  tiicy  gradually  meet  these  changed 
conditions.  A  sudden  and  permanent  i'ein()\al  of  this  l)ack  ])ressure  may 
affect  the  kidneys  profoundly.  For  this  reason  the  patient  should  either 
be  catheterized  or  drained  for  some  days  or  for  some  weeks  before  a  pros- 
tatectomy is  done.  The  I'cnal  function  should  be  accurately  determined,  partly 
by  chemical  analysis  of  the  urine,  but  chiefly  by  functional  tests  of  the  kidneys. 
As  pointed  out  forcibly  by  Louis  Frank,^  not  only  should  the  function  of  the  kid- 
neys be  determined  by  the  phenolsulphonephthalein  secretion,  but  by  the  estimate 
of  the  blood  urea,  and  if  greater  accuracy  is  demanded  by  the  determination 
of  Ambard's  coefficient.  No  matter  how  skillful  the  operative  technie  may 
be,  if  these  patients  do  not  show  satisfactory  renal  function,  disaster  is  likely 
to  follow.  If  in  doubt,  it  is  wise  to  drain,  either  by  an  indwelling  catheter 
or  by  a  suprapubic  drainage,  until  such  a  time  as  the  blood  urea  shows  that 
the  kidneys  are  working  satisfactorily. 

Suprapubic  prostatectomy  with  enucleation  of  the  prostate  according  to 
the  method  of  Squier  gives  very  satisfactory  results  in  most  cases.  Before 
the  operation  is  begun  a  large  soft  rubber  catheter  is  introduced  through  the 
penis  and  left  in  position.  This  catheter  should  be  new  so  that  it  will  not 
break.  The  bladder  is  exposed  suprapubically,  as  in  suprapubic  cystotomy. 
If  there  has  been  suprapubic  drainage  the  incision  is  made  from  the  drainage 
tract  to  the  pubis.  The  attachments  of  the  bladder  above  the  drainage  tract 
to  the  peritoneum  are  not  disturbed.  If  an  effort  is  made  to  enter  the  blad- 
der simply  by  dilating  the  old  drainage  tract,  the  peritoneum,  being  the 
loosest  attachment,  may  be  torn.  If  suprapubic  drainage  has  not  been  previ- 
ously established  the  prevesical  space  should  be  protected  by  gauze  packing 
before  the  bladder  is  opened.  After  opening  the  bladder  the  index  finger  of 
the  right  hand  is  inserted  into  the  internal  meatus  and  enucleation  is  begun 
by  breaking  through  the  prostatic  urethra  with  the  finger  near  the  roof  of 
the  urethra  and  a  little  to  the  right  side.  It  is  best  to  enucleate  the  prostate 
with  the  ungloved  hand.  The  gloved  left  index  finger  may  be  inserted  into 
the  rectum  and  the  prostate  pushed  up,  which  though  not  necessary,  will  aid 
materially  in  the  manipulation  (Fig.  597).  If  the  prostate  is  densely  adherent 
and  there  is  no  definite  line  of  cleavage  it  is  probably  cancerous  and  operation 
by  the  suprapubic  route  should  be  abandoned.  The  patient  is  then  drained 
and  a  radical  operation  for  cancer  of  the  prostate  undertaken  by  the  peri- 
neal route  several  days  later,  unless  the  disease  had  progressed  to  such  an 
extent  that  the  cancer  is  inoperable.  If  the  prostate  separates  fairly  easily 
the  finger  is  swept  down  on  its  side,  keeping  close  to  it,  and  loosening  it 
from  the  apex  of  the  gland  backward  (Fig.  598).  A  similar  procedure  is 
repeated  on  the  left  side.  Wherever  possible  at  least  a  small  strip  of  mucosa  of 
the  urethra  should  be  left.  After  enucleating  the  anterior  portion  of  the  pros- 
tate on  both  sides  the  enucleation  is  continued  from  before  backward,  still 


^Surg.,   Gynec.   and   Obst.,    Februarj%    1920,    p.    182,   et   seq. 


692 


OPERATIVE    SURGERY 


clinging  witli  tlie  finger  close  to  the  prostate.  After  it  has  been  sufficiently 
loosened  the  left  finger  is  removed  from  tlie  rectum,  the  glove  is  taken  off: 
by  a  nurse  and  a  fresh  glove  is  put  on  the  left  hand.  The  loosened  prostate 
is  caught  with  sponge  holding  forceps  and  moderate,  steady  traction  is  made 
on  the  forceps  while  the  enucleation  is  completed.  Dry  gauze  is  packed  firmly 
into  the  cavity  left  by  the  prostate  and  kept  in  position  for  three  or  four 
minutes. 

The  clots  are  removed  and  the   end  of  the   catheter  that   is  within  the 


Fig.   597. — Cross  section   of  the  first  stage  of  the  suprapubic   prostatectomy   of   Squier.     The   finger   is   about 
to  break  through  the  roof  of  the  prostatic  urethra.      (After   R.   C.   Brj'an.) 


bladder  is  seized  and  brought  up  through  the  suprapubic  wound.  A  stout 
black  linen  thread  is  tied  on  the  catheter  four  inches  from  its  tip  with  a  loop 
knot.  Into  this  linen  thread  are  folded  strips  of  iodoform  gauze  twisted  as  a 
cable.  The  linen  is  tied  over  the  gauze,  preferably  in  a  bow  knot,  and  the  ends 
are  left  long.  The  gauze  packing  that  was  in  the  bed  of  the  prostate  is 
removed,  and  the  iodoform  gauze  held  by  the  linen  thread  is  gradually 
introduced  into  the  bladder  Avhile  an  assistant  makes  traction  on  the  end 
of  the  catheter  protruding  from  the  penis.  The  iodoform  gauze  is  molded 
and  packed  into  the  cavity  left  by  removal  of  the  prostate.  An  end  of  the 
gauze  and  the  ends  of  the  linen  thread  around  the  gauze  are  brought  out 


PROSTATE,    TESTICLES,    AND    PENIS 


693 


1  lirouiili  llu'  wduihI.  a  liWixc  nil)l)('i'  1ul)t'  I'dr  ilraiiiajj,!'  is  inserted  in  1lie  l)la(l- 
cler  at  tlu'  upper  portion  of  the  M'ountl  (Fig.  599).  If  there  lias  not  been  a  pre- 
vious suprapultie  drainage  it  is  best  to  place  a  cigarette  drain  down  to  the  pre- 
vesical s])aee.  The  wound  is  partly  closed  by  interrupted  sutures  of  silkworm- 
gut.  C)ne  sutuic  of  silkworm-gut  just  belo.w  the  tube  is  inserted  but  not  tied 
till  after  the  })acking  has  been  removed. 

The  base  of  the  catheter  that  protrudes  from  the  urethra  is  clamped  with 
pedicle  forceps,  a  stout  cord  is  tied  to  the  handle  of  the  forceps  and,  after 
the  patient  has  been  placed  in  bed,  this  cord  is  carried  over  the  foot  of  the 
bed  and  a  two  pound  weight  is  attached  to  it.  This  Aveight  should  be  lifted 
for  ten  minutes  ever,y  hour  unless  there  is  considerable  bleeding.  This  pre- 
vents the  continuous  ischemia  of  the  tissues  that  are  pressed  upon  hy  the 
gauze.     Eight  hours  after  the   operation,   the  weight  is  removed   entirely  if 


Fig.    598. — The   finger   has   broken   through   the   prostatic   urethra   and   the   prostate    is   being   enucleated,    be- 
ginning at  its  apex  on  the  right  side.     (After  R.  C.  Bryan.) 


the  bleeding  has  ceased.  The  gauze  is  left  in  place,  however,  for  forty- 
eight  hours  and  after  taking  out  the  drainage  tube,  is  removed  by  pull- 
ing up  the  ligature  around  the  iodoform  gauze.  This  ligature  is  either 
untied  or  divided  with  scissors  and  the  gauze  is  removed.  If  the  gauze 
has  been  inserted  as  a  long  strip  and  an  end  brought  out  of  the  wound  along 
with  the  drainage  tube,  the  removal  is  easier.  A  mushroom  catheter  is  inserted 
and  the  silkworm-gut  suture  that  was  placed  at  the  time  of  operation,  but 
not  tied,  is  tied  and  reduces  the  extent  of  the  wound. 

This  method  of  controlling  hemorrhage  which  I  have  tried  in  recent  cases 
is  usually  satisfactory.     The  gauze  can  be  molded  and  packed  into  the  cavity 


694 


OPERATIVE    SURGERY 


left  by  removal  of  the  prostate  very  accurately  and  it  not  only  checks  bleed- 
ing more  promptly  than  rublu'r.  l)ut  may  be  made  to  exert  more  nearly  uniform 
pressure  on  the  irreguhir  contour  of  the  prostatic  bed  than  an  inflataljle  rubber 
bag.  Besides,  it  is  easy  to  obtain  and  is  not  subject  to  accidental  punctures  which 
may  be  disastrous  with  a  ruljber  bag. 


Fig.  599. — The  prostate  has  been  removed  and  the  drawing  shows  a  satisfactory  method  of  con- 
trolling hemorrhage,  which  is  fully  explained  in  the  text.  The  gauze  has  several  obvious  advantages  over 
a  rubber  bag.  It  has  greater  hemostatic  properties,  can  be  molded  more  accurately  into  the  bed  of  the 
prostate,  it  can  be  removed  without  dragging  all  of  the  catheter  through  the  bladder,  and  it  is  readily 
obtainable  in  any  operating  room. 


When  the  urethra  is  irritable,  an  excellent  method  of  controlling  bleeding 
is  to  pack  the  bed  of  the  prostate  with  a  long  strip  of  iodoform  gauze  and  gra.sp 
the  last  portion  of  the  gauze  with  sponge  forceps.  By  elastic  bands  going  from 
the  handle  of  the  forceps,  which  protrudes  from  the  wound,  to  adhesive  on 
the  patient's  skin,  constant  pressure  is  made  on  the  packing. 


PROSTATE,    TESTICLES,    AND   PENIS  695 

AVliile  tlie  sui)rai)ul)ir   route  is  preferable  in  most  prostatectomies  there 
are   certain   (•(uulii  imis   tliat   have   already    been    mentioned   which   make    the 
perineal  operation  of  II.  11.  Young  more  desirable.    Here,  a  curved  incision  is 
made  from  just  in  front  of  one  tuberosity  of  the  ischium  to  a  similar  point  on 
the   other   side.      It    curves   forward    so   the    apex    reaches   just    behind   the 
posterior  margin  of  the  scrotum.     A  flap  is  turned  down.     A  curved  sound 
is  inserted  into  the  urethra   and,  with  the  finger,  blunt  dissection  is  made 
on   each   side    of   the   urethra    and   the    rectum    is    gradually   pressed   back- 
ward.    The  central  tendon  and  the  rectourethralis  muscle  are  divided  close 
to   the   urethra.     The   bifid  retractor   of   Young   m^y   be   used   to   push  the 
rectum  back  while  these  structures  are  divided,  or  better  still,  the  rectum  can 
be  held  back  by  the  index  and  middle  fingers  of  the  left  hand.     The  recto- 
urethralis  musele  holds  the  rectum  very  close  to   the  urethra   and  it   is   im- 
portant to  avoid  injury  to  the  rectum  at  this  point.     The  bulb  of  the  penis  is 
retracted  forward.     An  injury  to  it  will  cause  an  annoying  bleeding.    The 
membranous  urethra  is  exposed  and  divided  by  a  longitudinal  incision  down 
to  the  sormd.     Each  margin  of  the  wound  in  the  urethra  is  caught  with  for- 
ceps and  the  finger  is  introduced  and  the  bladder  explored.     Often  the  finger 
cannot  reach  even  the  limits  of  the  prostate  but  it  will  at  least  serve  to  dilate; 
the  passage   and  to   determine   any  unusual   conditions  that   may  lie   within 
the  prostate.     The  finger  is  withdrawn  aiid  the  prostatic  tractor  of  Young 
is  introduced  closed.     It  is  spread  open  and  with  this  tractor  the  prostate  is 
draAvn  into   the   wound.      The   fascia    at   the    apex    of   the   pros-^ate   with   the 
muscle   fibers  that   overlie   its   capsule   are   stripped  to    each   side   by   blunt 
dissection  so  that  the  capsule  of  the  prostate  is  freely  exposed.     The  rectum 
is  firmly  retracted  and  the  prostate  steadied  by  the  prostatic  tractor  while 
two  incisions  are  made,  one  on  each  side  of  the  midline  about  an  inch  and  a 
half  apart.    These  incisions  are  carried  from  a  point  external  to  the  insertion  of 
the  prostatic  tractor  downward  and  backward  and  are  made  well  into  the  sub- 
stance of  the  prostate.    It  must  be  recalled  that  in  this  portion  of  the  prostate 
there  is  usually  a  considerable  thickness  of  normal  tissue  and  unless  this  is  cut 
through  to  the  adenomatous  portion  of  the  prostatic   enlargement,  the  true 
line  of  cleavage  will  be  missed  and  not  only  will  the  operation  be  more  diffi- 
cult but  it  will  be  unnecessarily  bloody. 

The  capsule  of  the  adenomatous  enlargement  is  demonstrated,  and  is  peeled 
up  by  the  insertion  of  a  blunt  instrument,  such  as  a  blunt  dissector  or  the 
handle  of  a  knife,  or  closed  blunt  scissors  the  blades  of  which  are  then 
spread.  After  the  separation  has  begun  sufficiently  to  admit  the  finger 
without  tearing  the  tissues,  the  finger  is  introduced  and  the  enucleation 
continued.  It  is  best  to  enucleate  partially  one  lobe,  then  completely  enu- 
cleate the  other,  and  after  this  remove  the  first  lobe.  In  this  way,  com- 
plete collapse  of  one  side  before  loosening  the  other  side  is  avoided.  As  the 
enucleation  proceeds  the  prostate  is  grasped  with  sponge-holding  forceps 
and  pulled  down,  which  aids  the  manipulations  considerably.     Traction  on 


696 


OPERATIVE    SL'RGERY 


the  prostatic  tractor  also  lielps.  After  Ijoth  loljes  have  been  delivered  the 
prostatic  tractor  is  turned  to  one  side  so  tliat  any  enlargement  of  the  middle 
lobe  may  be  brought  into  the  lateral  incision  in  the  capsule  and  enucleated. 
The  prostatic  tractor  is  folded  together  and  withdrawn,  and  the  finger 
is  again  inserted  into  the  Ijladdcr  to  determine  whetlier  any  stones  or  divertic- 
ula are  present.  The  cavitj^  left  by  removal  of  the  prostate  is  firmlj^  packed 
Avith  strips  of  iodoform  gauze.  If  the  prostatic  capsule  has  not  been  ex- 
tensively torn  1)y  tlie  removal  of  the  prostate  the  capsule  encloses  a  cav- 
ity which  can  be  readily  packed.     This  aids  greatly  in  controlling  hemorrhage. 


Fig.  600.— |-The  operation  of  H.  H.  Young  for  cancer  of  the  prostate.  The  urethra  has  been  opened 
through  the  perineal  incision,  the  tractor  is  inserted  into  the  bladder,  and  the  posterior  surface  of  the 
prostate  is  cleared,  showing  the  anterior  layer  of  the  fascia  of  Denonvillier.  The  dotted  line  shows  where 
the  dissection  should  proceed  in  order  to  keep  between  the  anterolateral  fascia  and  the  lateral  aspect 
of  the  prostate. 

Unfortunately,  however,  with  a  large  prostate  the  mucosa  of  the  bladder  is  often 
torn  during  the  enucleation  and  the  gauze  cannot  always  fill  the  cavity 
firmly.  This  is  an  objection  to  perineal  prostatectomy  because  in  the  suprapubic 
method  by  the  t?t'hnic  already  described  firm  pressure  can  always  be  made  with 
gauze.  In  small  firm  prostates,  however,  enough  of  the  capsule  can  usually  be 
left  by  perineal  extraction  to  permit  satisfactory  packing.  A  large  drainage 
tube  is  inserted  into  the  bladder  through  the  opening  in  the  membranous  ure- 
thra and  the  fascia  and  fibers  of  the  levator  ani  muscles  are  brought  together 


PROSTATE,    TESTICLES,    AND    PENIS 


697 


by  one  or  two  sutiu'cs  of  (•at<iut.  This  point  is,  according'  to  Young,  very 
important  in  prevenling  a  rectal  listnla  and  serves  to  keep  the  pressure 
from  the  rectum.  The  ends  of  the  gauze  packing  and  the  tube  are  brought 
out  at  the  k'ft  extremity  of  the  wound  and  not  in  the  midline.  The  wound 
is  closed  by  interrupted  sutures  of  silkworm-gut.  The  bladder  is  thoroughly 
irrigated  with  hot  boric  acid  solution  before  the  patient  leaves  the  table  but 
no  other  irrigation  is  done  until  after  forty-eight  hours,  as  this  may  wash 
away  the  elements  of  the  blood  which  promote  clotting.  The  gauze  packing 
is  removed  after  forty-eight  hours  and  the  tube  a  day  later. 


Ph 


601. — The   membranous    urethra   has   been    completely    divided.      The    prostate   is    turned    down   and    the 
bladder   wall    is   incised  just   abova   the    upper   limit   of   the   prostate. 


In  cancer  of  the  prostate  a  more  radical  operation  must  be  done.  H.  H. 
Young-  has  devised  a  technic  for  radical  operation  which  seems  satisfac- 
tory from  the  standpoint  of  a  cure  and  at  the  same  time  gives  the  pa- 
tient a  moderate  degree  of  urinary  control  after  the  operation.  The  pa- 
tient is  placed  in  the  extreme  dorsal  position  as  in  the  perineal  operation 
for  prostatectomy  and  the  procedures  are  carried  out  as  though  a  peri- 
neal prostatectomy  were  to  be  done,  up  to  the  step  of  incising  the  capsule. 
After  inserting  the   tractor   the   prostate   is   drawn   down   and  the   posterior 


-Young,   H.   H.:     Jour.   Am.   Med.   Assn.,    1917,    Ixi.x,    1591,   et   seq. 


698 


OPERATIVE    SURGERY 


layer  of  Denonvillier's  fascia  is  divided  at  the  apex  of  llic  i)r()state  on  each 
side,  thus  exposing  tlie  anterior  layer  of  this  fascia  whicli  covers  the  pros- 
tate and  the  seminal  vesicles  (Fig.  600).  The  posterior  surface  of  the  pros- 
tate and  seminal  vesicles  is  freed  and  then  the  lateral  surfaces  of  the 
prostate  are  exposed  ])y  hluiit  dissection.  Tiie  operator  keeps  within  the  an- 
tero-lateral  prostatic  fascia,  separating  it  from  tlie  prostate,  which  thus  avoids 
hemorrhage  and  at  the  same  time  preserves  the  vascular  supply  and  the  peri- 
neal nerves.  This  step  Young  thinks  is  very  important.  By  resecting  the 
anterolateral  fascia  and  passing  between  it  and  the  lateral  and  the  anterior 


Fig.  602. — The  bladder  has  been  completely  incised,  the  vesicles,  the  vasa  and  the  surrounding 
tissue  are  mobilized,  and  the  right  vas  is  divided  and  tied.  Vascular  tissues  in  this  region  are  clamped, 
if  possible,  before  division. 


part  of  the  prostate,  a  certain  amount  of  urinary  control  can  be  preserved. 
After  separating  this  fascia  the  membranous  urethra  is  completely  divided 
just  in  front  of  the  prostatic  tractor.  Here  also  the  anterolateral  prostatic 
fascia  must  be  respected.  The  prostate  is  pulled  doAvn  and  gradually  drawn 
outward  (Fig. '601). 

The  bladder  wall  is  incised  anteriorly,  close  to  the  upper  limit  of  the 
prostate,  and  the  incision  is  continued  by  scissors  on  each  side.  In  this  man- 
ner the  trigone  of  the  bladder  is  fully  exposed.  The  trigone  is  incised  about 
a  third  of  an  inch  below  the  ureteral  orifice,  in  such  a  way  that  the  walls  of 


PROSTATE,    TESTICI.es,    AND   PENIS 


699 


the  bladilor  are  carefully  ml:  Ihrou^'li  hut  llie  seminal  vesicles  heneath  are 
not  divided.  The  l)hid(h'r  is  tlieii  jnished  up  l)lun1ly  thus  exposing  the  tissues 
around  the  front  of  the  seminal  vesicles  and  vasa  deferentia.  These  struc- 
tures are  freed  en  masse  and  the  fascia  which  contains  the  l)lood  supply  at  the 
upper  end  of  the  seminal  vesicles  on  each  side  is  ligated  and  divided  as  far 
as  possible  from  the  jn-ostate.  The  vas  deferens  is  isolated  on  each  side,  freed 
well  above  the  tip  of  the  seminal  vesicle,  drawn  down,  clamped  and  divided 
(Fig.  602).  The  mass  including  the  prostate  and  its  surrounding  tissue  is 
then  removed  in  one  piece. 


Fig.  603.— The  prostate  with  the  surrounding  tissue  is  removed  in  one  mass  and  the  upper  border 
of  the  bladder  wound  is  sutured  to  the  upper  part  of  the  urethra  with  interrupted  sutures  ot  tannea  or 
chromic  catgut,  and  the  knots  are  tied  externally.  Similar  sutures  are  placed  anteriorly  and  ttie  rest  oi 
the    bladder   wound    is    closed   with   a    continuous   suture. 

The  bladder  is  drawn  down  and  the  upper  portion  of  the  urethra  is  su- 
tured to  the  upper  portion  of  the  wound  in  the  bladder  by  interrupted 
sutures  of  chromic  or  tanned  catgut,  tied  externally  (Fig.  603).  A  catheter 
is  then  inserted  through  the  urethra  and  into  the  bladder  and  the  anastomo- 
sis between  the  urethra  and  the  bladder  is  completed  by  interrupted  sutures 
of  tanned  or  chromic  catgut.  The  longitudinal  opening  in  the  bladder  which 
remains  posterior  to  the  anastomosis  with  the  urethra  is  closed  with  a  con- 
tinuous suture  of  tanned  or  chromic  catgut.    A  small  cigarette  drain  of  iodo- 


700  *  OPERATIVE   SURGERY 

form  gauze  is  placed  behind  the  line  of  sutures  and  the  levator  ani  muscles 
are  brought  together  by  one  or  two  sutures  of  chromic  catgut.  The  skin  is  closed 
in  the  usual  manner.  The  catheter  is  left  in  and  fastened  to  the  penis  by  ad- 
hesive plaster.  The  drainage  is  removed  in  two  or  three  days.  It  is  not  neces- 
sary to  pass  sounds  or  instruments  after  the  operation. 

In  Young's  experience  many  patients  after  this  operation  have  satisfactory 
control  of  the  bladder. 

THE  SEMINAL  VESICLES,  VAS  DEFERENS,  AND  TESTICLES 

Disease  of  the  seminal  vesicles  may  require  operation  for  drainage  or, 
occasionally,  for  excision  of  the  seminal  vesicles.  When  they  are  to  be 
opened  the  operation  of  Fuller  has  given  good  results.  The  patient  is 
placed  in  the  knee  chest  position  with  the  knees  sharply  flexed.  An  incis- 
ion is  made  on  each  side  of  the  anus,  opening  up  each  ischiorectal  fossa,  and 
the  extremities  of  these  incisions  are  joined  by  a  transverse  incision  in  front 
of  the  rectum.  With  the  left  finger  in  the  rectum  the  rectal  wall  is  separated 
from  the  prostate  and  vesicles  by  blunt  dissection.  After  the  separation  a 
long  grooved  director  is  thrust  into  the  apex  of  the  vesicle  while  using  the 
finger  in  the  rectum  as  a  guide  to  direct  the  course  of  the  director.  A  scalpel 
is  shoved  along  the  groove  of  the  director  until  it  enters  the  apex  of  the  sem- 
inal vesicles  and  a  cut  of  about  an  inch  and  a  quarter  is  made  Avith  the  blade 
of  the  knife  along  the  course  of  the  vesicle,  freely  laying  open  its  cavity.  The 
incision  is  dilated  with  the  finger  tip.  The  other  seminal  vesicle  is  opened 
in  a  similar  manner.  If  there  is  a  considerable  mass  of  granulation  tissue 
the  cavity  is  curetted.  Each  cavity  is  packed  with  strips  of  gauze,  the  ends 
of  which  protrude  from  the  external  w^ound,  and  two  soft  rubber  drainage 
tubes  are  placed  between  the  gauze  and  the  rectum.  The  incision  is  closed 
with  interrupted  sutures  except  at  the  transverse  part  Avhich  is  left  open 
for  drainage  and  for  the  exit  of  the  tubes  and  the  ends  of  the  gauze  packing. 
The  gauze  is  removed  after  three  days  and  the  tubes  four  days  later. 

A  better  method  of  operating  on  the  seminal  vesicles  is  through  an  ex- 
posure used  by  Cunningham,  of  Boston.  Here  the  vesicles  are  approached 
as  in  a  perineal  prostatectomy.  He  does  not  open  the  urethra,  but  depresses 
the  prostate  wdth  a  fork  retractor  and  fully  mobilizes  its  under  surface. 

Occasionally  it  may  be  necessary  to  drain  the  vas  deferens.  This  operation 
can  be  readily  performed  by  isolating  the  vas  deferens  in  the  upper  portion 
of  the  scrotum  and,  under  local  anesthesia,  dividing  it.  The  upper  end 
of  the  vas  is  split  and  stitched  into  the  wound  if  it  is  intended  to  drain 
the  seminal  A^esicles  also.  Reunion  of  the  vas  can  be  made  by  end-to-end 
sutures  of  fine  arterial  silk  after  a  strand  of  silkAvorm-gut  has  been  placed 
in  its  lumen  and  brought  out  by  a  needle  through  the  vas  at  a  point  about 
half  an  inch  from  the  line  of  union.  After  j)lacing  the  sutures  the  silkworm- 
gut  is  left  in  position  and  later  it  may  be  withdrawal. 


PROSTATE,    TESTICLES,    AND    PEXIS  701 

AnastoiiiKsis  of  ilic  \;is  with  ihc  ei)i(rul\ mis  is  doiic  in  sterility,  in  Avliii-li 
lluM'e  is  a  l)l(>fkago  of  soiiu'  jxu'tion  ol'  ilic  \as  or  of  llie  epididymis.  The  epi- 
didymis and  vas  may  be  satisfactorily  exposed  through  an  incision  iu  the 
posterior  part  of  the  scrotum.  The  veins  and  larger  blood  vessels  should  be 
avoided.  Before  undertaking  this  operation  any  stricture  that  may  be  in  the 
urethra  or  inflammation  of  the  seminal  vesicles  should  be  cured  and  the  patency 
of  the  vas  from  the  epididj'mis  to  the  prostatic  urethra  should  be  demonstrated 
by  injecting  into  the  vas  methylene  blue  and  noting  if  it  appears  in  the  ure- 
thra. The  vas  is  exposed  and  split  longitudinally  and  about  twenty  or  thirty 
drops  of  methylene  blue  are  sloAvly  injected.  The  dye  will  appear  in  the 
urine  if  there  is  no  obstruction  or  in  the  seminal  discharges  after  massage 
of  the  seminal  vesicles.  If  this  test  is  satisfactory  the  epididymis  is  opened 
by  cutting  off  a  small  piece  with  a  pair  of  scissors.  It  must  be  demonstrated 
by  a  microscope  that  the  fluid  within  this  portion  of  the  epididymis  con- 
tains spermatozoa,  and  if  thev'  are  not  found  at  this  point  other  openings 
must  be  made  into  the  epididymis  or  into  the  testicle  until  spermatozoa  are 
found.  The  widely  split  vas  is  then  sutured,  with  a  few  interrupted  sutures 
on  a  fine  needle  to  the  opening  in  the  epididymis  or  testicle.  Arterial  silk 
is  an  excellent  suture  for  this  purpose. 

Anastomosis  of  the  vas  and  the  epididymis  done  by  the  method  described, 
which  was  devised  by  Martin,  of  Philadelphia,  is  more  or  less  indirect.  Af- 
ter the  capsule  of  the  epididymis  has  been  incised  and  a  portion  of  the  epi- 
didymis tubule  cut  the  vas  is  split  and  the  open  incision  in  the  vas  is  sewed 
to  the  capsule  of  the  epididymis  over  the  raw  surface  of  the  incised  tubule  of 
the  epididymis.  There  is  conseciuently  considerable  distance  to  be  bridged 
by  the  epithelium  lining  the  vas  and  the  epididymis. 

V.  D.  Lespinasse,^  of  Chicago,  has  devised  an  operation  which  is  a  direct 
anastomosis  between  the  epididymis  tubule  and  the  vas.  An  incision  is  made 
in  the  scrotum  and  through  the  tunica  vaginalis.  The  epididymis  is  exposed 
and  the  point  of  obstruction  is  found.  The  vas  is  opened  by  a  short  longi- 
tudinal incision  and  a  colored  fluid,  as  methylene  blue,  is  injected  into  the 
central  end  of  the  vas.  If  the  fluid  appears  in  the  urethra  it  is  a  demonstra- 
tion that  the  vas  is  open  from  the  point  of  incision  to  the  urethra  and  the 
operation  can  be  proceeded  with.  If  the  vas  is  not  open  the  operation,  of 
course,  will  be  abandoned  unless  the  point  of  occlusion  can  be  found  farther 
up.  If  the  operation  is  to  be  completed  the  capsule  of  the  epididymis  above 
the  obstruction  is  carefully  incised  down  to  the  tubule.  All  of  the  layers  of 
the  capsule  are  removed  from  the  epididymis  tubule  with  great  care  and  the 
epididymis  tubule  itself  should  not  be  injured  or  opened  at  any  point.  It 
protrudes  through  the  opening  thus  made  and  a  loop  of  the  tubule  is 
selected  whose  direction  is  in  the  long  axis  of  the  body  of  the  epididymis. 
A  suture  of  fine  arterial  silk  (00000)  on  a  Xo.  19  bayonet  pointed  needle 
is  passed  through  the  wall  of  the  epididymis  tubule,  down  its  lumen,  and 
out  again  through  the  wall   of  the  tubule  about  three   mm.   from  the  point 


sLespinasse,   \*.    D. :     Jour.   Am.   !Med.   Assn.    Ixx,   Feb.    16,    191S.   p.    448    et   seq. 


702 


OPERATIVE    SURGERY 


of  entrance  (Fig.  604).  This  is  followed  by  leal^age  of  epididymal  secretion 
Avliieh  is  drawn  into  a  small  syringe  and  examined  for  spermatozoa.  If 
spermatozoa  are  present  this  suture  is  passed  through  the  incision  that 
has  been  previous!}'  made  into  the  vas  and  out  through  its  wall.  The 
other  end  of  the  suture  is  threaded  into  a  needle  and  passed  through 
the  wall  of  the  vas  in  a  similar  manner  at  the  other  end  of  the  incision  in 
the  vas.  In  this  way  the  epididymis  tul)ule  is  drawn  into  the  longitudinal 
incision  in  the  vas  (Fig.  605).     Sutures  of  catgut  are  placed  on  each  side  of 


Fig.     604. — The     operation     of     Lespinasse  for 

anastomosis    of    the    vas    and    the    epididymis.  A 

fine    silk    suture    is    inserted    into    a   tubule    of  the 
epididymis. 


Fig  605. — The  suture  in  the  tubule  is  carried 
through  the  incision  in  the  vas,  as  explained  in 
the    text.      (Lespinasse.^ 


Fig.    606. — The   other    sutures   are   placed   to    hold    the   vas   to   the   capsule   of   the   epididymis.      (Lespinasse.) 

the  longitudinal  incision  in  the  vas,  include  the  full  thickness  of  the  wall  of 
the  vas,  and  are  carried  to  the  capsule  of  the  epididymis.  These  hold  the 
incision  in  the  vas  open.  Two  other  sutures  are  placed  into  a  portion  of  the 
Avail  of  the  vas  but  do  not  penetrate  to  its  lumen  or  epithelial  lining  and 
hold  the  vas  to  the  capsule  of  the  epididymis  a  short  distance  from  the 
ends  of  the  longitudinal  incision  into  the  vas  (Fig.  606).  When  these 
two  sutures  are  tied  they  should  leave  the  intervening  segment  of  the  vas 
without  tension  so  that  the  union  between  the  vas  and  the  epididymis  tubule 
is  in   accurate    approximation   and   without    strain.      The   upper    end   of   the 


PROSTATE,    TESTICLES,    AND    PENIS  703 

ori^'iiKil  suliii-c  is  t  ln'ciidcd  on  ii  loii^'  li;i  j^'cdoni  iummIIc  and  al'ler  the  lesticle 
lias  l)(M'ii  r('|)lai'(>(l  in  llic  sc-rdliim  the  iummIIc  ])ierees  the  scrotum  from  williiii 
outA\ar(l.  In  from  one  to  tAVo  woel<s  wluMi  llie  wall  of  the  epididymis  tubule 
within  the  grasp  of  this  suture  has  become  cut  by  this  suture  it  is  gently 
removed. 

In  tubereuh^sis  of  the  epididymis,  the  epididymis  can  often  be  excised 
-without  removing  the  body  of  the  testicle,  if  the  disease  is  not  too  far  ad- 
vanced. The  incision  is  made  through  the  scrotum,  external  to  the  epididymis 
or  if  the  epididymis  is  adherent  to  the  skin  the  tissue  that  is  bound  by  the 
adhesions  is  included  in  an  oval  incision.  An  incision  along  the  junc- 
tion between  the  epididymis  and  testicles  is  made  on  the  outer  side  and 
divides  only  the  tunica  vaginalis  opposite  the  body  of  the  epididymis  but 
goes  deeper  at  the  globus  major  and  globus  minor.  The  head  of  the  glo- 
bus major  is  separated  by  sharp  dissection  from  the  testicle  and  then  the 
body  of  the  epididymis  is  freed.  All  of  this  dissection  is  from  the  outer 
side.  On  the  inner  side  the  large  vessels  to  the  testicle  are  in  contact  with 
the  epididymis  and  dissection  here  must  be  particularly  careful.  By  trac- 
tion the  structures  of  the  cord  are  recognized  and  injury  to  the  vessels  may  be 
avoided.  The  dissection  is  continued  by  separating  the  vas  up  to  the  internal 
ring.  Here  it  is  doubly  clamped  and  divided,  the  proximal  end  is  cauterized 
with  carbolic  and  ligated.  Any  other  foci  of  the  disease  are  excised.  After 
controlling  the  bleeding  by  suturing  the  tunica  and  the  raw  surface  with  cat- 
gut, the  external  wound  is  closed  with  interrupted  or  continuous  mattress  su- 
tures of  fine  tanned  catgut. 

In  epididymitis  incision  of  the  epididymis  often  gives  relief  when  noth- 
ing else  wall.  It  will  probably  require  a  general  anesthetic.  An  incision 
is  made  through  the  scrotum  either  over  the  epididymis  or  in  the  upper  front 
part  of  the  scrotum  so  that  the  testicle  can  be  delivered  into  the  wound.  The 
epididymis  is  punctured  a  number  of  times  with  a  large  needle  and  returned 
to  the  scrotum.  If  there  is  suspicion  of  pus  the  scrotum  is  incised  imme- 
diately over  the  epididymis  W'hich  is  punctured  in  several  places. 

Removal  of  the  testicles  may  be  necessary  for  tuberculosis  or  for  a  benign 
or  malignant  growth.  An  incision  is  made  over  the  front  upper  part  of  the 
scrotum  from  the  level  of  the  external  abdominal  ring  downw^ard  for  a  suffi- 
cient distance  to  deliver  the  diseased  testicle  into  the  Avound.  Such  an  in- 
cision is  usually  all  that  is  necessary  in  tuberculosis  or  in  benign  tumors. 
The  cord  is  doubly  ligated  with  catgut  after  being  crushed  and  the  testicle 
is  drawn  up  into  the  wound  and  removed.  It  is  necessary  to  clamp  and  tie 
every  bleeding  surface.  The  wound  is  closed  by  a  continuous  mattress  suture 
of  fine  tanned  catgut. 

If  there  is  distinct  malignancy  the  operation  should  be  radical.  An  in- 
cision is  made  over  the  inguinal  canal  from  a  point  one  inch  external  to  the 
internal  ring,  doAvnward  over  the  external  ring,  and  onto  the  scrotum.  The 
inguinal  canal  is  exposed  as  in  the  operation  for  hernia  and  the  flaps  of  the 
aponeurosis  of  the  external  oblique  are  retracted.     The  vas  is  dissected  from 


704  OPERATIVi:    SURGERY 

its  bed  and  followed  as  far  as  possible  into  tlie  pelvis  after  di\iding  the 
posterior  wall  of  the  iniiuiiial  eanal.  The  vas  deferens  is  then  doubly  ligated, 
di^'ided  and  the  stump  is  cauterized.  The  spermatic  vessels  are  followed 
up  into  the  lumbar  region,  all  of  this  being  done  extraperitoneally.  They 
are  d(ni1)ly  ligated  and  divided.  The  other  tissues  of  the  cord  are  divided 
and  the  cord  is  dissected  down  to  below  the  external  inguinal  ring.  The 
testicle  with  the  tumor  and  surrounding  tissues  is  delivered  into  the  wound 
and  removed  along  with  the  cord.  As  much  tissue  as  i^ossible  is  taken 
and  if  any  part  of  the  scrotum  is  adherent  this  portion  should  be  removed 
along  with  the  testicles,  the  original  incision  being  continued  downward  so 
as  to  include  the  adherent  part  of  the  scrotum.  Every  bleeding  point  is 
clamped  and  tied  with  fine  catgut. 

Undescended  or  misplaced  testicle  is  best  treated  by  the  general  prin- 
ciples of  the  Bevan  operation.  Here  the  incision  is  made  as  in  the  radical 
operation  for  inguinal  hernia  and  does  not  involve  the  scrotum.  After  ex- 
posing the  inguinal  canal  the  eremaster  muscle  and  the  fascia  are  divided, 
the  sac  of  j)eritoneum  which  contains  the  testicle  is  opened  and  the  un- 
descended testicle  exposed.  The  peritoneum  above  the  testicle  is  separated 
from  the  cord  very  carefully  and  the  upper  portion  is  divided  and  closed 
by  sutures  or  a  ligature  as  in  tying  a  hernial  sac.  The  loAver  pouch  of  peri- 
toneum serves  as  a  tunica  vaginalis  and  is  closed  around  the  testicle  loosel}' 
with  a  pursestring  suture.  The  testicle  with  its  covering  sac  is  lifted  from 
its  bed  and  gentle  traction  is  made  on  the  cord.  This  demonstrates  the 
bands  that  prevent  the  descent  of  the  testicle  into  the  scrotum.  These  bands 
are  usuall}'  connective  tissue  and  can  be  cut  with  scissors  or  torn  with  forceps. 
The  cord  is  so  dissected  that  only  the  blood  vessels  and  the  vas  are  left  and 
these  are  separated  from  the  posterior  layer  of  the  peritoneum  by  blunt  dis- 
section as  far  as  possible.  In  this  w^ay  the  cord  is  lengthened  for  several 
inches.  A  thorough  lengthening  of  the  cord  is  an  important  step  in  the  oper- 
ation. The  finger  is  inserted  into  the  scrotum  and  burrows  a  pocket  for  the 
testicle.  This  pocket  is  enlarged  by  pushing  down  closed  pedicle  forceps 
and  spreading  the  blades.  The  testicle  is  inserted  into  this  pocket  and  is  held 
by  a  pursestring  suture  passed  through  the  pilloAvs  of  the  external  inguinal 
ring  but  tied  lightly  so  as  not  to  compress  the  circulation  of  the  cord.  The 
wound  is  closed  by  shoving  the  cord  to  the  inner  angle  of  the  wound  and  unit- 
ing Poupart's  ligament  Avith  the  conjoined  tendon  over  the  cord. 

When  it  is  impossible  to  bring  the  testicle  into  the  scrotum  by  this  means 
some  of  the  spermatic  vessels  which  are  the  chief  obstacle  to  its  descent 
may  be  divided.  This,  however,  is  of  doubtful  expediency,  for  while  the 
testicle  may  not  actually  undergo  gangrene,  division  of  the  spermatic  ves- 
sels so  profoundly  affects  its  nutrition  that  it  will  probably  atrophy.  Gess- 
ner,  of  New  Orleans,  has  demonstrated  experimentally  that  atrophy  of  the 
testicle  follows  ligation  of  the  spermatic  vessels. 

Hydrocele  may  often  be  cured  by  the  simple  method  of  tapping  the  hy- 
drocele with  a  large  aspirating  needle  or  a  small  trocar  and  cannula  and  in- 


PROSTATE,    TESTICLES,    AND   PENIS  705 

jet'tiiig  from  ten  lo  thirly  (lr()})S  of  pure  earljolic  acid  alter  drawing  oJ'f  all 
of  the  fluid.  ]n  ta])])in<>'  the  hydrocele  a  point  is  selected  on  the  anterior  sur- 
face of  the  scrotum  that  is  free  from  veins.  While  the  hydrocele  is  steadied 
^vitli  the  hand  a  small  amount  of  novocaine  solution  is  injected  into  the  scro- 
tum and  a  short  incision  of  about  one-quarter  of  au  iuch  is  made  with  a  knife. 
Through  this  incision  a  large  aspirating  needle  or  a  small  trocar  and  cannula 
are  inserted.  The  trocar  is  withdrawn,  the  fluid  evacuated  and  the  carbolic 
is  slowly  injected  through  the  cannula.  The  skin  surrounding  the  point 
of  puncture  is  anointed  with  vaseline  to  protect  it  from  the  carbolic  when 
the  cannula  is  withdrawal.  The  cannula  is  then  quickly  removed,  Avhile 
grasping  the  punctured  scrotum  with  a  piece  of  gauze  v^diich  will  absorb  any 
carbolic  that  may  leak  from  the  end  of  the  cannula.  The  scrotum  is  gently 
massaged  to  distribute  the  carbolic  evenly  over  the  inner  surface  of  the 
tunica  vaginalis.  Carbolis  is  less  painful  for  injection  and  less  dangerous  than 
iodine. 

Considerable  swelling  follows  this  procedure  which  gradually  subsides 
in  most  cases.  If  it  has  not  all  disappeared  in  three  weeks  the  injection  may 
be  repeated.    This  procedure  wall  cure  many  cases  of  simple  hydrocele. 

If  the  hydrocele  is  not  cured  after  tw-o  or  three  injections  at  intervals  of 
several  weeks  the  sac  is  excised  or  everted.  Eversion  of  the  sac,  or  the  so- 
called  bottle  operation,  is  done  by  making  an  incision  through  the  anterior 
surface  of  the  scrotum.  The  testicle  is  delivered  into  the  w-ound,  the  sac 
opened,  and  its  edges  are  sutured  behind  the  testicle  so  as  to  turn  its  inside 
out  and  appose  the  whole  of  its  interior  to  the  raw  surface  of  the  wound  which 
will  usually  absorb  the  secretion  from  the  sac.  In  many  cases,  however,  pock- 
ets form  and  this  operation  is  not  satisfactory.  Excision  of  the  sac  neces- 
sarily gives  the  largest  number  of  cures  of  hydrocele  and  if  carbolic  injections 
have  not  been  successful  excision,  particularly  in  a  large  thick  sac,  is  the  op- 
eration of  choice.  An  incision  is  made  through  the  anterior  surface  of  the 
scrotum  down  to  the  hydrocele  sac.  The  various  coverings  are  separated 
until  the  sac  is  reached  but  not  opened.  It  is  then  bluntly  dissected  free 
from  its  surroundings  as  far  as  possible  and  delivered  into  the  wound.  Oc- 
casionally the  hydrocele  sac  is  of  such  a  nature  that  it  can  be  dissected  free 
and  removed  without  being  opened.  This,  of  course,  is  an  anatomic  peculiarity 
and  does  not  often  occur.  After  freeing  as  much  of  the  sac  as  possible  it  h 
opened  and  trimmed  away  close  to  the  testicle,  taking  care  to  leave  no  re- 
dundant fold.  The  vessels  are  clamped  and  tied  and  the  scrotal  w^ound  is 
closed  wath  a  continuous  mattress  suture  which  everts  the  edges  of  the  skin 
wound  and  prevents  the  dartos  muscle  from  pulling  it  in. 

An  operation  for  varicocele  should  be  performed  only  wdien  enlargement 
of  the  veins  of  the  cord  is  marked  and  has  resisted  medical  treatment  for 
many  months.  It  should  not  be  done  in  a  youth  about  the  age  of  puberty 
except  when  the  disease  is  very  marked  and  the  symptoms  are  decided.  When 
it  is  necessary  to  remove  varicose  veins  resection  of  the  scrotum  is  also  in- 
dicated.    A  varicocele  that  is  not  sufficiently  pronounced  to  be  accompanied 


706  OPERATIVE    SEKGERY 

with  a  markedly  relaxed  scrotum  does  not,  as  a  rule,  require  operation.  It 
is  just  as  essential  to  remove  the  redundant  scrotum  and  so  afford  support 
to  the  testicle  as  it  is  to  remove  the  enlarged  veins. 

The  scrotum  is  caught  with  an  Allis  forceps  in  the  median  raphe  at 
about  the  junction  of  its  upper  and  middle  thirds  and  also  at  the  junction 
of  its  middle  and  posterior  thirds.  The  scrotum  is  lifted  up  and  the  re- 
dundant portion  is  clamped  with  pedicle  forceps.  This  part  is  cut  away 
with  scissors  while  making  tension  upon  it.  The  incision  is  just  on  the  proxi- 
mal side  of  the  forceps  so  the  tissues  that  are  injured  l)y  the  clamp  are 
excised.  The  bleeding  vessels  are  quickly  caught  with  hemostats.  Every 
bleeding  point  must  be  clamped.  After  complete  hemostasis  has  been  secured 
with  the  clamps,  the  vessels  are  tied  with  fine  plain  catgut.  The  varicose 
veins  over  the  left  cord  are  exposed  by  an  incision  along  the  cord  and  the  vas 
deferens,  together  with  the  spermatic  artery,  are  freely  delivered  into  the 
wound.  The  spermatic  artery  is  identified  if  possible.  If  this  can  be  done 
the  spermatic  artery  Avitli  one  or  two  veins  and  the  vas  deferens  are  gently 
isolated  and  separated  from  the  rest  of  the  dilated  veins,  but  if  it  is 
impossible  the  largest  varicose  veins  are  freed  and  about  three  inches  are 
removed  after  doubly  ligating  wnth  catgut  the  upper  and  lower  portions  of 
the  veins.  If  the  spermatic  artery  can  be  recognized  and  isolated  along 
with  the  vas  deferens  and  a  few  other  veins  the  rest  of  the  veins  may  be  safely 
removed  after  ligating  them  with  catgut  close  to  the  testicle  below  and  at  the 
upper  portion  of  the  scrotum.  It  is  best  to  put  two  ligatures  on  each  end  to 
avoid  the  possibility  of  the  ligature  slipping.  The  ends  of  one  set  of  liga- 
tures are  left  long.  After  excising  the  intervening  segment  of  vein  the  stumps 
are  tied  together  by  the  long  ends  of  the  ligatures. 

When  in  doubt  it  is  much  better  to  take  out  too  few  veins  than  too  many, 
as  the  resection  of  the  redundant  portion  of  scrotum  will  give  such  support 
to  the  testicle  and  structures  of  the  cord  that  extreme  radical  procedures 
in  removal  of  veins  of  the  cord  are  not  necessary.  It  is  highly  important  to 
leave  the  spermatic  artery  for,  as  has  already  been  mentioned,  the  excellent 
experimental  work  of  Gessner,  of  New  Orleans,  has  demonstrated  the  prob- 
ability of  complete  atrophy  of  the  parenchyma  of  the  testicle  after  ligation 
of  the  spermatic  artery.  After  carefully  securing  all  bleeding  points  and 
tying  them  with  fine  catgut  the  wound  is  closed  Avith  a  continuous  mattress 
suture  of  tanned  catgut.  The  suture  is  applied  in  the  line  of  incision.  A 
second  row  of  sutures  uniting  the  edges  of  the  skin  may  be  placed  to  secure 
more  accurate  apposition.  Such  a  wound  makes  a  scar  that  resembles  very 
closely  the  median  raphe  and  if  the  incision  has  been  properly  made  there  are 
no  teats  or  irritating  protuberances  that  often  follow  a  transverse  incision 
for  removing  the  redundant  scrotum. 

External  urethrotomy  for  deep  strictures  has  already  been  described. 
Internal  urethrotomy  is  but  seldom  practiced.  Occasionally,  however,  there 
may  be  a  marked  decided  narrowing  of  the  external  meatus  which  it  is  neees- 


PROSTATK,    TESTICLES,    AND    PENIS  707 

s;iry   1o   split.     Tliis   is  done   undvr   local   ancs1liesi;i    by    iiijcetiiig  tiie   tissues 
around  the  lucalus  and  incising'  the  meatus  at  its  lowest  i)oint. 

Cireiiuu'ision  may  l)e  done  under  loeal  auesthesia.  Jf  ou  an  infant  care 
must  be  observed  to  see  that  the  adhesions  between  the  glans  penis  and  the 
l)rei)uee  are  well  separated.  By  cutting  down  the  prepuce  without  separating 
these  adhesions  anteriorly,  the  meatns  may  be  split  and  the  glans  injured, 
which  will  be  followed  by  considerable  bleeding.  The  prepuce  is  grasped 
anteriorly  on  each  side  of  the  midline  by  two  small  hemostats.  Slight  trac- 
tion is  made  and  if  there  is  any  reason  to  expect  adhesions  between  the  glans 
and  the  prepuce  a  pair  of  curved  scissors  is  inserted  within  the  prepuce  and 
gently  spread  so  as  to  separate  the  adhesions  sufficiently  to  make  a  dorsal 
incision  in  the  prepuce  without  injuring  the  glans.  A  straight  incision  is  then 
carried  down  the  dorsum  of  the  prepuce  to  a  point  about  opposite  the  corona 
(Fig.  607).  This  must  be  determined  before  too  much  traction  is  made  upon 
the  prepuce,  as  otherwise  the  incision  may  be  carried  too  far.     Any  further 


Fig.   e07. — Tl-e   first  stage   of  circumcision.     Tlie  Fig.    608.— The   circumcision   is  completed, 

dorsal  incision  is  made  and  the  dotted  line  shows 
the  incision  for  removal  of  the  prepuce,  which 
should   be  just   distal   to   the   corona. 

adhesions  are  noAV  thoroughly  separated  and  the  prepuce  is  trimmed  from 
the  upper  extremity  of  this  dorsal  incision  around  to  the  frenum  on  each 
side  parallel  with  the  corona.  Sufficient  tissue  should  be  left  at  the  frenum 
to  allow-  for  suturing  without  contraction.  The  bleeding  points  are  caught 
with  mosquito  forceps  and  tied  with  fine  catgut.  The  wound  is  closed 
with  a  continuous  suture  of  fine  tanned  or  chromic  catgut  which  begins 
on  the  right  of  the  frenum,  is  carried  around  the  incision  and  terminates 
a  short  distance  from  its  beginning  (Fig.  608).  This  leaves  a  slight  in- 
terval betAveen  the  beginning  and  the  end  of  the  suture,  which  allows  for 
swelling  or  erection.  If  the  tissues  in  the  frenum  are  not  entirely  covered 
by  this  suture  one  or  two  additional  interrupted  sutures  of  fine  catgut  are 
placed. 

In  epispadias  the  urethra  is  merely  a  groove  on  the  dorsum  of  the  penis. 
Such  a  deformity  often  accompanies  exstrophy  of  the  bladder  and  as  the  best 
operation  for  exstrophy  of  the  bladder  is  transplantation  of  the  ureters,  the 


708 


OPERATIVE    SURGERY 


chief  object  of  the  ()j)erati<)ii  Jur  episjjadias  in  the  presence  of  exstropliy  of 
the  bhidder  will  be  for  sexual  intercourse. 

The  operation  of  CantAvell  is  probabl}"  the  most  satisfactory  operation  for 
epispadias.  This  depends  upon  the  fact  that  in  this  disease  the  two  corpora 
cavernosa  are  much  more  looseh'  attached  to  each  other  than  in  a  normal 
penis  and  can  be  readily  separated.  The  first  step  in  this  as  in  any  plastic 
operation  on  the  penis  is  to  provide  for  drainage  of  the  bladder,  either 
through  the  perineum  or  sui)rapul)ically,  in  order  to  divert  the  stream  of 
urine  while  the  wound  in  the  penis  is  healing.  The  perineal  operation  is  best 
here  and  can  be  quickly  done  by  a  short  incision  through  the  perineum  on 
a  sound  in  the  urethra.  On  each  side  of  the  groove  of  the  epispadias  that 
represents  the  urethra  an  incision  is  made  along  the  junction  of  the  mucosa 
and  the  skin  extending  from  the  symphysis  to  the  extremity  of  the  glans. 
These  incisions  extend  down  to  the  corpora  cavernosa  but  not  into  them. 
The  urethra  is  freed  as  a  flap  from  its  bed  and  held  up  while  the  two  cor- 


Fig.  609. — The  operation  of  Cantwcll  for  epispadias.  A,  shows  the  epispadias,  with  the  dotted  line 
indicating  the  incision  for  the  formation  of  the  urethra.  B,  shows  the  relation  of  the  skin  flap  which  is 
to  form  the  new  urethra.  The  corpora  are  not  firmly  attached  to  each  other  in  epispadias.  C,  the  flap  for 
the  urethra  is  made  and  is  sunk  between  the  two  corpora  which  are  easily  separated  in  this  deformity. 
D,   cross   section  representing  the   operation  completed. 

pora  cavernosa  are  separated  from  each  other  until  the  skin  on  the  lower 
surface  of  the  penis  is  reached.  The  mobilized  urethra  is  now  placed  in  the 
bottom  of  this  wound  and  fixed  by  sutures.  A  sound  is  laid  in  the  urethra 
and  the  skin  of  the  urethra  is  sutured  over  it.  The  corpora  cavernosa  are 
brought  together  hy  a  few  sutures  and  the  skin  is  closed  over  them  in  the 
usual  manner.  The  illustrations  show  the  steps  of  the  operation  (Fig.  609). 
The  base  of  the  flap  of  the  urethra  is  at  the  root  of  the  penis  so  that  there 
should  be  no  trouble  about  the  nutrition  of  this  transplanted  mucosa  of  the 
urethra. 

Hypo.spadias  is  more  common  than  epispadias  and  may  exist  in  various 
degrees.  When  the  defect  is  slight  the  operation  of  Beck  may  be  done.  An 
incision  is  made  around  the  urethral  orifice  and  over  the  under  surface  of 
the  urethra  toward  the  perineum.  The  urethra  with  the  corpus  spongiosum 
is  dissected  from  the  corpora  cavernosa  for  a  sufficient  distance  so  that  it 
can  be  readily  drawn  through  a  stab  wound  in  the  glans  penis.  A  stab  wound 
is   made   with   a    sharp   narrow   knife    and   the   urethra   is   brought    through 


PROSTATE,    TESTICLES,    AND   PENIS 


709 


and  fastened  l)y  a  few  sntnres  to  llic  ed^cs  o\'.  the  artiiieial  meatus.  The 
skin  is  then  sutured  over  that  ])oi1ion  of  the  urethra  that  has  been  trans- 
phnited.  This  operation  ean  only  be  done  when  there  is  a  very  slight  defect 
and  but  little  curvature  of  the  penis.  If  there  is  a  marked  contraction  the 
operation  of  Beck  is  likely  to  reproduce  it. 

If  the  penis  is  bowed  the  first  procedure  is  to  straighten  it.  This  may 
be  done  by  a  transverse  incision  on  the  under  surface  of  the  penis  just  be- 
hind the  g'lans  and  the  incision  is  sutured  longitudinally.  When  this  de- 
formity is  marked  the  operation  of  straightening  the  penis  should  be  under- 
taken some  time  before  the  plastic  operation  is  done  for  constructing  the 
urethra. 

J.  E.  Thompson,-*  of  Galveston,  Texas,  has  described  the  embryology  of 
hypospadias  together  with  plastic  procedures  for  correcting  this  deformity 
is  a  very  excellent  article.  As  he  has  said  it  is  important  that  no  skin  which 
contains  hair  follicles  should  be  used  for  construction  of  the  urethra. 


Fig.  610. — The  Thompson-Russell  operation  for  hypospadias.  The  penis  is  straightened  by  a  trans- 
versed  incision  which  by  traction  becomes  diamond  shaped.  A  tunnel  is  made  in  the  head  of  the  penis 
which  is  enlarged  later  on.     The  dotted  lines  indicate  the  incision  for  the  flaps. 

An  operation  that  can  often  be  done  and  which  gives  satisfactory  results 
is  that  of  C.  H.  Mayo.  After  straightening  the  penis  the  wound  is  allowed 
to  heal  and  at  the  second  operation  a  large  tunnel  is  made  through  the  glans 
penis  to  a  point  a  little  to  one  side  of  the  site  of  the  normal  opening.  A 
flap  long  enough  to  reach  without  tension  through  this  tunnel  in  the  glans  to 
the  urethral  opening  is  cut  from  the  dorsal  surface  of  the  penis  and  prepnce 
with  its  base  at  the  anterior  margin  of  the  prepuce.  It  must  be  wide  enough 
to  be  rolled  into  a  tube  of  about  the  size  of  a  normal  urethra.  It  is  sutured 
together  as  a  tube  with  the  skin  surface  inside,  using  fine  sutures  of  tanned 
or  chromic  catgut.  This  tube  is  drawn  through  the  tunnel  in  the  glans,  and 
the  tip  is  sutured  to  a  bed  prepared  for  it  close  to  the  urethral  opening.  The 
tube  is  allowed  to  heal  in  position  and  after  an  interval  of  a  few  weeks  the 


4Thompson,  J.   E.:     Tr.   Southern   Surg.   Assn.,   1916,  p.   223,   et  seq. 


710 


OPERATIVE    SURGERY 


base  of  the  flap  is  cut.    A  few  weeks  later  this  tube  made  from  the  transplanted 
fold  of  prepuce  is  united  to  the  end  of  the  urethra. 

In  the  operation  of  Russell,  flaps  are  taken  from  the  side  of  the  penis  ad- 
joining the  groove  which  represents  the  defective  part  of  the  urethra.  In  all 
of  these  operations  perineal  drainage  of  the  bladder  must  be  the  first  stage. 
In  Thompson's  modification  of  the  Russell  operation  the  penis  is  first  straight- 
ened by  a  transverse  incision  just  under  the  glans.  The  penis  being  straight- 
ened, a  large  tunnel  is  made  through  the  glans  with  a  narrow-bladed  knife 
(Fig.  610).  This  tunnel,  which  begins  about  the  normal  site  of  the  meatus, 
emerges  a  short  distance  below  the  glans.  An  incision  is  carried  around  the 
penis  in  the  prepuce  about  one-eighth  of  an  inch  from  the  corona.  A  second  in- 
cision is  made  in  the  skin  of  the  penis  beginning  one-eighth  of  an  inch  be- 


Fig.    611. — The  flaps  are  dissected   and  are  united, 
so  forming  the  new  urethra.      (Thompson-Russell.) 


Fig.  612. — The  new  urethra  is  brought  througn 
the  enlarged  tunnel  in  the  head  of  the  penis.  The 
lower  skin  incision  is  sutured  over  the  new  urethra 
(Thompson-Russell). 


hind  the  urethral  opening,  and  curving  backward  and  outward  on  each  side 
around  the  urethral  opening.  It  is  then  carried  forward  about  one-third  of 
an  inch  from  the  margin  of  the  urethral  opening  and  parallel  to  the  groove 
which  represents  the  defective  part  of  the  urethra.  This  incision  is  carried 
over  the  dorsum  of  the  penis  and  along  the  prepuce  from  one  side  to  the 
other,  parallel  to  and  behind  the  incision  that  has  been  previously  made  in 
the  prepuce.  The  dorsal  part  of  this  incision  is  parallel  to  and  behind  the 
first  incision  made  through  the  prepuce,  so  these  two  incisions  form  a  flap  of 
the  prepuce  which  resembles  a  clergyman's  stole.  This  flap  is  about  one- 
quarter  of  an  inch  wide.  It  is  carefully  dissected  so  as  not  to  separate  the 
outer  edges  of  the  posterior  portion  of  the  flap  any  further  than  possible. 


PROSTATE,  TESTICLES,  AND  PENIS 


711 


111  this  ^\•ay  the  A'aseuUir  supply  of  tlie  Uap  Avill  be  preservetl.  The  skin  sur- 
faces of  these  flaps  are  turned  to  face  each  other  and  the  edges  are  sutured 
with  fine  tanned  or  chromic  catgut.  The  suturing  is  so  applied  as  to  turn 
in  the  skin  edges  (Fig.  611),  The  tube,  which  is  formed  by  suturing  these 
flaps,  is  drawn  through  the  tunnel  in  the  glans  and  is  fastened  in  position  Avith 
a  fcAV  sutures.  The  margins  of  the  skin  on  the  side  of  the  penis  are  sutured 
together  over  this  urethra  from  behind  forward  so  as  to  cover  the  urethra 
as  far  as  the  glans  (Fig.  612).  The  defect  left  on  the  prepuce  by  raising  this 
flap  is  easily  corrected  by  suturing  the  margins  of  the  skin  on  the  prepuce  to- 
gether (Fig.  613).  One  advantage  of  the  operation  is  that  it  can  often  be 
done  in  one  stage. 

Amputation  of  the  penis  may  be  partial  or  complete.  Before  beginning 
amputation  of  the  penis,  the  cancerous  area  is  thoroughly  cauterized  with 
the  actual  cautery.  This  not  only  prevents  infection  by  sterilizing  the 
septic  tissues  but  guards  against  an  even  greater  danger  of  implantation  of 


Fig.  613. — The  completed  operation    (Thompson-Russell). 

the  cancer  cells  in  the  raw  surface.  In  amputation,  after  applying  a 
tourniquet  at  the  root  of  the  penis  an  incision  is  made  through  the  skin 
completely  around  the  penis  and  about  three-fourths  of  an  inch  or  more 
from  the  apparent  border  of  the  disease.  The  skin  is  dissected  back  for  half  an 
inch  and  the  dorsal  artery  and  vein  are  exposed,  ligated  and  divided.  Both 
corpora  cavernosa  are  divided  transversely  and  the  urethra  with  its  sur- 
rounding tissue  is  divided  half  an  inch  in  front  of  the  corpora  cavernosa. 
The  ends  of  the  corpora  cavernosa  are  whipped  over  with  catgut  sutures  to 
control  the  bleeding.  A  short  incision  is  made  in  the  skin  just  over  the 
urethra,  which  is  slightly  split  opposite  this  point  and  is  sutured  to  this  in- 
cision in  the  skin. 

Usually  it  is  wise  to  dissect  both  inguinal  regions  whenever  the  penis 
is  amputated  for  cancer.  This  is  done  by  making  an  incision  parallel  with 
Poupart's  ligament  and  just  above  it.  The  upper  margin  of  the  skin  is  re- 
tracted and  the  fat  and  fascia  are  dissected  down  to  the  aponeurosis  of  the 


712  OPERATIVE    SURGERY 

external  oblique.  This  mass  of  tissue  is  dissected  with  gauze  down  to  the 
border  of  Poupart's  ligament.  At  the  outer  extremity  of  the  incision  the 
mass  is  dissected  to  the  fascia  lata  and  then  inward  to  the  tissues  over  the 
femoral  arterj-.  Dissection  is  then  begun  at  the  inner  portion  of  the  wound 
and  is  carefully  carried  toward  the  femoral  canal.  Care  is  taken  to  avoid 
injury  to  the  saphenous  vein,  or  at  least  to  recognize  it  and  clamp  it  before 
it  is  divided,  if  it  appears  to  be  involved.  By  working  along  the  plane  of 
the  fascia  lata  and  the  aponeurosis  of  the  external  oblique  block  dissection 
can  be  readily  accomplished.  The  region  at  the  femoral  canal  requires  care- 
ful dissection  with  a  good  light  and  a  sharp  knife.  The  mass  is  finally  freed 
from  the  femoral  artery  and  vein. 

If  the  inguinal  region  is  to  be  dissected  for  cancer  it  should  be  done 
as  a  block  dissection  that  has  just  been  described.  This,  however,  is  unneces- 
sarily radical  in  inflammatory  conditions,  and  while  it  is  really  easier  than 
removing  isolated  glands  there  is  a  danger  of  edema  of  the  scrotum  following 
the  block  dissection  if  done  on  both  sides. 

When  complete  amputation  of  the  penis  is  necessary  the  scrotum  is  split 
along  its  median  raphe  which  gives  thorough  exposure  of  the  corpus  spongio- 
sum. The  corpus  spongiosum  is  separated  from  the  corpora  cavernosa  and 
divided.  The  urethra  is  dissected  as  far  as  the  triangular  ligament.  The  in- 
cision is  carried  around  the  root  of  the  penis,  the  suspensory  ligament  is  di- 
vided, and  the  crura  are  separated  from  the  pubic  bones.  The  vessels  of  the 
crura  are  clamped  and  tied.  The  urethral  stump  is  split  and  the  edges  of  the 
urethra  are  sutured  to  the  posterior  part  of  the  scrotal  Avound.  The  skin  is 
closed  in  the  usual  manner  after  providing  for  drainage.  Both  inguinal  re- 
gions should  always  be  dissected  when  cancer  is  sufficiently  advanced  to  re- 
quire complete  amputation  of  the  penis. 


INDEX 


Abbe,  operation  on  stricture  of  esophagus,  323 

operation   for   "trigger"   finger,   359 
Abdominal  incisions,  508-519 

closure  of,  514-519 
Adson,   operation   on  facial  nerves,   153 
on  gasserian  ganglion,   285-287 
on  liypoplivsis,  276 
Albee,  inlay  method  of  bone  graft,  164-167 
method    of    bone    graft    in    Pott 's    disease, 

168-171 
operation  on  spina  bifida,  301,  302 
Amputation,  arm,   331-350 
at  elbow,  343-345 
at  hip  joint,  383-385 

method  of  Wyeth,  383-384 
at  knee  joint,  379-380 

method   of   Gritti-Stokes,   380-381 
at  shoulder  joint,   347-349 
at  tarsometatarsal  joiiit,  374-375 
cineplastie,  341-343 
Lisfranc,    374-375 
motor  stump  in,  341-343 
of  arm,  general  principles  of  operations  in, 

^331-336 
of  fingers,  336-339 
of  forearm,  341-343 
of  foot,  method  of  Chopart,  375 
method  of  Pirogoff,  375 
method  of  Syme,  375-376 
of  hand,  339-341 
of  leg,  376-379 

method  of  Hey,  376-379 
of  lower  extremity,  370-385 
general  principles  in,  370-371 
observation  by  Starr  on,  370-372 
of  thigh,  380-383 
of  toes,   371-373 
of  upper  arm,  345-347 
of  upper  extremity,  349-350 
method  of  LeConte,  249-250 
method  of  Crile,  349-350 
Andrew,  operation  for  hernia,  485-487 
Anesthesia,  intratracheal,  433-434 

spinal,   289-290 
Aneurisms,   arteriovenous,   133-140 
treatment  of,  by  Matas,  135 
by  quadruple  ligation,  139 
by  quintuple  ligation,  139-140 
excision,  by  Lexer,   75 
extirpation   of,    125-126 
needling  of,  Macewen,  118 
of  special  arteries,  treatment  of,  126-132 
traumatic,  treatment  of,  132 
treatment  of,  by  digital  compression,  120 
method  of  Finney,   118-119 
bv  gradual  obliteration,  Halsted,  119-120 
Matas,   119-120 


Aneurisms,  treatment  of — Cont  "d 

by  introduction  of  wire,  118,  119 
by  ligature  method  of  Anel,  121 
^f  Antyllus,  121 
of  Bi-asdor,  121-122 
of  John  Hunter,   121-122 
of   Pasquin,    121-122 
of  Purmann,  121-122 
of  Wardrop,  121-122 
by  Matas,   122-125 
by  Eeid,   120 
method  of  Finney,  118-119 
Ani  pruritus,  operation  for,  659-661 

operation   of   Terrell,   659-661 
Ankle  joint,  operation  for  deformities  of,  401- 
413 
for  flail  joint  in,  407-409 
for  flail  joint  in,  Bradford,  408-410 
for  excision  of,  411 
Aorta,   abdominal,   experimental  resection,   89 

ligation   of,   110 
Appendicitis,  operations  for,  623-637 
Appendectomy,  623-637 

McBurney  incision  for,  623-627 
treatment  of  stump  in,   628-631 
results  of;,  632-634 
Appendix,  operation  for  abscess  in,  634-637 
Arm,  amjDutations  of,  331-350 

lymphedema  of,  operations  for,  366-368 
operation   for,   method   of   Handley,   366- 

367 
operation  for,  method  of  Kondoleon,  368 
operations  on,  331-369 
upper,  amputation  of,  345-347 
Artery,   anterior   tibial,   ligation   of,    116 
axillary,  ligation  of,   108 
brachial,  ligation  of,  109 
common  carotid,  ligation  of,  101-102 
common  iliac,  ligation  of,  110-111 
dorsalis  pedis,  ligation  of,  116 
external  carotid,  ligation  of,  102-103 
external   iliac,   ligation   of,   112-113 
femoral,   ligation   of,   113-115 
inferior  thyroid  artery,  ligation  of,  107- 
innominate,  ligation  of,   100-lOi 
internal  carotid,  ligation  of,  105 
internal  iliac,  ligation  of,  111-112 
popliteal,  ligation  of,  115-116 
posterior  tibial,  ligation  of,  117 
radial  and  ulnar,  ligation  of,  109-110 
subclavian,   ligation   of,   105-107 
superior  thyroid,  ligation  of,  104 
temporal,    traumatic    aneurism   of,    132 
vertebral,  ligation  of,  107 
Arteriovenous  aneurisms,  133-140 

treatment  of,  by  Matas,  135 
Arthi'odesis  of  elbow,  355-356 


713 


714 


INDEX 


Arthroplasty,  420421 

of  knee  joint,  420 

of  hip  joint,  420-421 
Ascites,  operation  for,  534-5?)5 
Ashhurst's  operation  for  excision  of  the 

tongue,    248-249 
Astragalus,  excision  of,  411 


Babcoek's  operation  on  spina  bifida,  300-302 
Baldwin's  operation  for  reconstruction  of  the 

nose,  232-233 
Balfour 's   modification    of    operation    for    ex- 
cision of  stomach,  574-578 
ojieration   for  removal  of   the   spleen,   539- 

542 
operation  on  thyroid  glands,  330 
Bands,   pericolonic,   637-639 
Bartlett's  operation  on  thyroid  glands,  330 
Beck's,  Carl,  operation  for  chronic  empyema, 
443 
operation  for  hypospadias,   708-709 
Biernheim's  extirpation  of  aneurism,  126 
method  of  transfusion  of  blood,  64-65 
Bevan's  operation  for  abscess  of  lungs,  444- 
448 
operation   for   diverticulum   of  esophagus, 

323 
operation  for  early  cancer  of  rectum,  645- 

648 
operation    of    laryngectomy,    318-321 
operation  for  undescended  testicle,   705-700 
Beyea's  oi^eration  for  ptosis  of  stomach,  545- 

546 
Bifid  spine,  296-302 

classifications  of,  296-298 
with  hydrocephalus,  297-298 
Bile   duct,    operations    on,    528,    529,    532-534 
reconstruction  of,  34,  532-534 
Guerry,  534 
Mayo,  W.  J.,  533-534 
Sullivan,  533 
Binnie  's  operation  for  ligation  of  blood  ves- 
sels, 98-99 
operation   for   excision  of  upper  jaw,   253- 
254 
Bladder,  operations  on,  684-689 

operation  for  diverticulae,  684-685 
Blair,  operation  for  deformity  of  lower  jaw, 
255-256 
operation  for  excision  of  tongue,  249-251 
Bloodgood,  operation  for  direct  inguinal  her- 
nia, 489 
Blood  vessels,  lateral  wounds  of,  90-91 
ligation  of,  97-117 
ligation  of,  method  of  Binnie,  98-99 

method  of  Horsley,  77-86 
suturing,  69-91 

indications  for,  69-70 
instruments  used  in,  76-78 
Bone,  plating  fractures  of,  33 
Bone  wax,  57 

in  hemorrhage  from  skull,  264 
Bones,  operations  on,' 157-171 

biologic  repair,  in  injured,  157-160 


Bones — Cont  'd 

fractures  of,  162-165 

graft,  inlay  method  of  Albee,  164-167 

intramedullary,  metliod  of  Hoglund,  163- 

104 
nutrition  in,  159 
in  Pott 's  disease,  method  of  Albee,  168- 

171 
principles  of,   157-161 
Wolff 's  law  in,  158 
plating  of,   33,  160,  161 
ununited  fractures  of,  166-168 
Bowel  (see  Intestine) 
Bradford,   operation  for  flail  joint   of  ankle, 

408-410 
Brachial  plexus,  operations  on,  153-155 
method  of  Sharpe,  154-155 
paralysis,    transplantation    of   muscles    for, 
155-156 
Ba-ain,  adhesions  of,  269-272 
congenital  hernias  of,  276-279 
control  of  hemorrhage  for,  266 
decompression,    operations    on,    279-283 

method    of    Gushing,    279-281 
location  of  centers  in,  264-266 
method  of  Chipault,  264,  265 
method   of   Eeid,    265 
method  of  Einkenberger,  265,  266 
meningocele  of,  operation  for,  277-279 
operations    on,    261-287 
puncture   of   corpus   callosum  in,   274-275 
puncture  of  ventricle  of,   275 
Branchial  cysts,  operations  on,   305 

fistula   of,   operations  on,   305 
Breast,  operations  on,  462-476 
Brickner,  operation  for   subacromial  bursitis, 

369 
Brown,  John  Young,  method  of  enterostomy, 

599-601 
Bunion,  operations  for,  405-406 

C 

Cannon  and  Murj^hy,  lateral  intestinal  anasto- 
mosis,  32 

Cannon  and  Washburn,  gastric  pain,  31 

Cantwell,  operation  for  epispadias,  708 

Cardioh'sis,  435-436 

Carotid   gland,    operations   on,   323-324 

Carrel,  method  of  suturing  blood  vessels,  71- 
73 

Castration,  703-707 

Cecosigmoidostomy,  622 

Cecum,  resection  of,  m.ethod  of  Horsley,  610- 
613 

Cerebellum,  operations  on,  267-268 

Cerebrospinal  fluid,  pressure  of,  289 

Cervical  ribs,   308 

Cervical  sympathetic,  operations  on,  325-326 
method  of  Jonnesco,  326 
method  of  C.  H.  Mayo,  325-326 

Cheeks,   operation   on   defect   of,   207-210 

Chipault,    method    of    location    of    centers    in 
brain,  264-265 

Cholecystectomy,  522-527 
method  of  Willis,  527 


INDEX 


715 


C'lioltH-ystoeiitoidstoniy,    5;50-5.">2 

mothod  of  Horslcy,  r);50-5o2 
Cholooystotomy,   527-i528 
Cliolocystostomy,  G02 
Choledocluis,  operations  on,  528,  529,  532-534 

reeonsti'iiotion   of,   532-53-1 
Cineplastie   amputation,   341-343 
Circulation,  reversal  of,  30,  31 
Circumcision,  707,  708 
Citrate,  niethoil  of  transfusion  of  blood,  Lew- 

isolin's,  66-68 
Clavicle,  excision  of,  461 
Cleft  palate,  operations  on,  195-198 
method  of  Lane,  195,  198 
method  of  Langenbeek,  195-198 
Closure    of    abdominal   incisions,   514-519 
Club   foot,   operations   for,   401-413 

intractable,  operations  for,  411-413 
Coagulation  of  blood,  70,  71 
Coccygeal  dermoid,  operation  for,  661,  662 
Codman,    operation   for    subacromial    bursitis, 

369 
Coffey,  operation  for  cancer  of  the  pancreas, 
535-538 
operation  for  ptosis  of   stomach,   543 
principles    in    enterostomy,    592-597 
Colev,  modification  of   Bassini   operation   for 

hernia,    483,    484 
Colon,  obstruction  of,  617,  618 
resection  of,  610-618 

method  of  Mikulicz,  618 
Complications   of   oj^eration;    infection,   shock 

and  hemorrhage,  51-58 
Corpus  eallosum,  puncture   of,  274,  275 
Crile,  block  operation  on  neck,   312-316 
oi^eration  for  amputation  of  upper  extrem- 
ity,  349-350 
method  of  transfusion  of  blood,  62 
Cubbins  and  Abt,  irritating  lubricants  in  the 

peritoneum,    74 
Cunningham,    operation    on    seminal    vesicles, 

700 
Cystotomy,  perineal,  688-689 
suprapubic,    685-688 

T> 

Dandv,   W.   E.,   operation   for   hvdrocephalus, 

273,    274 
Davis,  J.  S.,  method  of  skin  grafting,  182 
operation    on   columna    of   nose,    228 
operation  on  orbital  socket,  220-222 
Dermoid,    coccygeal,    operations    for,    661-662 

sacral,   operations  for,   661,   662 
Diaphragmatic  hernia,  operations  for,  505-507 
Diffuse  lipoma  of  neck,  324,  325 
Diverticulum  of  esophagus,  321-323 
Dowd,    method    of    operation    on    tuberculous 

glands,  309,  310 
Drainage  in  surgery,  35-43 
surgical,  classification  of,  36 
surgical,    material,   41 
Dupuvtren,    contraction   of   fingers,   operation 

for,    358 
Dura,  transplantation  of  fascia  for  defect  in, 
269-272 


E 

Ears,  operations  on,  222-224 

for  reconstruction  of,  method  of  Roberts, 
224 
method  of  Szymonowski,  223-224 
Edema,   local,    cause    of,    38 
operation  for,  Handley,  38 
Ivondoleon,  38 
Elbow,  amputation  at,  343-345 
arthrodesis  of,   355,   356 

method  of  Jones,  355,  356 
excision  of,  351-353 
Elephantiasis,  operations  for,  427,  428 

method  of  Ivondoleon,  427,  428 
Elsberg,  method  of  repair  of  defect  of  nerve, 

146-148 
Embolism,    pulmonary,    Trendelenburg    opera- 
tion for,  454-458 
Emjivema,  chronic,  operations  for,  method  of- 
Beck,   443 
method  of   Estlander,  440-442 
method  of  Fowler,  443 
method  of  Robinson,  443 
method   of   Schede,  442-443- 
operations   for,   437-443 
Endo-aneurvsmorrhaphy,    method     of    Matas, 

123-125 
Enterostomy,  589-602 

method  of  Brown,  John  Young,  599-601 
using  principle  of  Coffey,  592-597 
method  of  Long,  589-592 
Epididymis,  operations  on,  703 
Epigastric    liernia,    operations    for,    504,    505 
Epilepsy,  operations  for,  268-272 
Epispadias,  operation  for,  70S 

method  of  Cantwell,  708 
Esser,  method  of  treatment  of  depressed  sears, 

186 
Esmarch,  operation  for  ankvlosis  of  lower  jaw, 

257,  258 
Esophagus,  operations  on,  322,  323 
for  cliverticulum  of,   322,   323 
method  of  Bevans,  323 
method  of  Judd,  322,  323 
stricture   of,   method  of  Abbe,   323 
method  of  Mixter,  323 
method    of    Ochsner,    323 
Excision   of   joints,   350-355 
elbow,   351-353 
shoulder,  353-355 
wrist,  350,   351 
Extremity,  lower,   operations  on,   370-431 
Eye  lids,  operations  on,  210-222 

method  of  Gibson,  215,  217,  218 
method  of  Gillie,  210-213 


Face   and  mouth,   oxjerations  on,   187-260 
Face,  operations  for  tumors  of,  238-240 
Facial   paralysis,    operation   for,    150-153 

method  of  Adson,  153 
Ferguson,   oi^eration   for   hernia,   487-489 
Fifth  nerve,  j^eripheral  operations  on,  258-260 
Fingers,  amputation  of,  336-339 

deformities  of,  operation  for,  358-366 
' '  drop  ' ',  operation  for,  358,  359 


716 


INDEX 


Fingers — Cont  M 

Dupiiytrcn's   contraction   of,   operation   for, 

358 
"liammer",  operations  for,  o.j8,  359 
infection   of,   356,   357 
reconstruction  of  tendons  of,   361-30G 

method  of  Dean  Lewis,  361-363 
transplantation    of    tendons    of,    method    of 

Murphy,  364-366 
''trigger",  operations  for,  method  of  ALbe, 
359 
metliod  of  Weir,  359 
' '  web ' ',  operations  for,  360,  361 
Finney,   method    of   treating   aneurisms,    118, 
119 
operation  for  pyloroplasty,  549-551 
Fistula,  in  ano,  operation  for,  650-652 
branchial,   operations  on,   305 
of  rectum,  operations  for,  650-652 
rectovesical,  operation  for,  651,  652 
salivary,   operation  for,   240-242 
Fissure   in   ano,    operation   of,    652 
Flail  joint   of  ankle,   operations  for,  407-409 
Foot,  amputation  of,  method  of  Chopart,  375 
method  of  Pirogoff,  375 
method  of  vSyne,  375,  376 
club,  operations  for,  401-413 
Forearm,  amputation  of,  341-343 

transplantation  of  tendon,  method  of  Mur- 
phy,  364-366 
Forehead,  operations  on,  236-238 
Foreign  bodies  in  the  peritoneum,  42 
Fowler,  operation  for  chronic  empyema,  443 
Fractures  of  bone,  plating  of,  33,  161-165 
Frazier,  operation  on  gasserian  ganglion,  283- 
285 
operation  for  spina  bifida,  298-300 
Frisch,  method  of  tendon  suture,   362 
Fuller,    operation   on   seminal   vesicles,    700 

G 

GaU  bladder,  removal  of,  522-527 

method   of   Willis,    527 
Ganglion,  gasserian,  operations  on,  283-287 
Gangrene,   threatened,   ligation   of   femoral 
vein,  95,  96 
surgical  treatment  of,   30,   31,   94-96 
Gasserian  ganglion,  operations  on,  32,  283-287 
method  of  Adson,  285-287 
method  of  Frazier,  283-285 
Gastrointestinal  tract,  surgery  of,  31-32 
Gastroenterostomy,  indications  for,  563 
method   of  Eoux,   569 
posterior  technic  of,  564-568 
Gastrostomy,  578-581 
Gastrotomy,  578,  579 

Gessner,  on  ligation  of  si^ermatic  vessels,  706 
Gibson,  operation  on  eye  lids,  215,  217,  218 
Gillie's    method     of    tubing    j^edicles     in 

plastic  surgery,  178-180 
operation  on  eye  lids,  210-213 
Gland,  carotid,  operation  on,  323,  324 
Goldtliwait,   operation  for  chronic   dislocation 
of  patella,  413 


Grant's  metliod  of  tying  knots,  48-50 
Guerry,    opei'ation    for    reconstruction    of   bile 
duct,  535 

H 

llalsted,    treatment    of    aneurism    by    gradual 
obliteration,    119,    120 
ox^eration   for    cancer    of    mammary    gland, 

467-469 
operation   for   direct   inguinal   hernia,   489, 
490 
Hallux  valgus,  operation  for,  405,  406 

method  of  C.  H.  Mayo,  405 
Hand,  amputation  of,  339-341 

infection   of,   356,   357 
Handley,  operation  for  local  edema,  38 
for  lymphedema  of  arm,  366-367 
Harelij),  operations  on,  187-192 
operation  of  C.  H.  Mayo,  168 
oiJeration  of  Owen,  190-191 
operation  of  Eose,  188-190 
double,  operations  on,  191-193 
Harris,    operation    for    hernia    of    mammary 

gland,   465-467 
Heart,  operations  on,  453-458 
Heineke-Mikulicz,    operation    of    i^yloroplast}-, 

551 
Hemorrhage  from  bone,  57 
from  brain,  control  of,  266 
from  skull,  control  of,  264 
in  surgical  o]3erations,  56-58 
Hemorrhoids,    operation   for,    654-659 

method   of   Terrell,   654,   655 
Hernia,  477-507 

diajahragmatic,  oj^erations  for,  505-507 
direct   inguinal,    operations   for,   method   of 
Bloodgood,  489 
method  of  Halsted,  489,  490 
double  inguinal,  incision  of  Judd,  513,  514 
epigastric,  'operations  for,  504,  505 
femoral,    operations    for,    493-499 

method   of   Seelig,   495-497 
femoral,   reconstruction    of   Poupart's   liga- 
ment, method  of  Horsley,  497,  498 
general    principles   in   operations   for,   477- 

479 
incisional  or  ventral,  operations  for,  502-504 

method  of  W.  J.  Mayo,  503 
inguinal,   operations  for,   479-493 
method  of  Andrews,  485-487 
method  of  Bassini,  480-488 

Coley's  modification  of,  483,  484 
methocl  of  Ferguson,  487-498 
method  of  LaRoque,  490-493 
method  of  Macewen,  491 
of  the  brain,   256-279 
umbilical,  operations  for,  499-502 
Hip  joint,  anrputation  at,  383-385 
method  of  Wyeth,  383,  384 
arthroplasty  of,  420,  421 
excision  of,  416,  417 
Hoglund,     method     of     intramedullary     bone 

graft,   163-164 
Horsley,   J.   S.,   modification   of   operation   of 
Beyea  for  ptosis  of  stomach,  545, 
546 


iXDi:x 


717 


Iloi'sloy — Cunt  M 
operation  on  eliolocystontorostomy,  530-  532 
operation  for  pyloroplasty,   552-564 
veeonstruc'tion  "of    Poupart's    ligament    in 

femoral  hernia,  497-499 
resection  of  eeeinn,  610-(il.3 
resection   of  laroe   intestine,   610-616 
resection  of  small  intestine,  605-609 
reversal  of  circulation  of  blood,  92-95 
suturing-  blood   vessels,    77-86 
transfusion  of  blood,  60,  77-86 
Iluber   and   I.ewis,   method    of   prevention    of 

neuromas,  334 
Huer,  method  of  operation  on  hypophysis,  276 
Hydrocele,   operation   for,   705 
Hydrocephalus,   operations  for,  33,   272-275 
method  of  W.  E.   Dandy,  273,   274 
with  bifid  spine,  297,  298 
Hydronephrosis,  operations  for,  674 
Hypophysis,    operations    on,    275,    276 
method  of  Adson,  276 
method  of  Heuer,  276 
method  of  McArthur,  275,  276 
Hypospadias,  operations  for,  708-711 
method  of  Beck,  708,  709 
method  of  C.  H.  Mayo,  709,  710 
method  of  Eussell,  709-711 
method  of  Thompson,  709-711 


Incisions,   abdominal,   508-519 

Infection  in  surgical  operations,  51-55 

Infusion,  intravenous,  66,  67 

Ingrowing  nail,  operations  for,  406,  407 

Instruments  in  surgery,  44,  45 

Instruments   used   in   blood   vessel   suturing, 

76-78 
Intestines,  operations  on,  585-622 

lateral  anastomosis  of,   619-622 

Meckel's  diverticulum  of,  618,  619 

obstruction  of,  598-602 

general  j)rineiples  of  resection  of,  603-605 

resection  of  large,  method  of  Horsley,  610- 
616 

resection  of  small,  method  of  Horsley,  605- 
609 
Intestinal  resection,  603-622 

suturing,   585-589 
Intratracheal  anesthesia,  433,  434 
Intravenous   infusion   of   Locke's   solution    or 
salt   solution,   66,   67 


Jackson,    operation   for    cancer    of    mammary 
gland,  469 
for  pericolonie  bands,  638 
Jaw,  lower,  operations  on,  254-258 
ankylosis  of,  256-258 

method  of  Esmarch,  257,  258 
defects  in,   206-208 

operation  of  Blair  for  deformities  of,  255, 
256 
upper,  operations  on,  252-254 

operation  of  Binnie  for  excision  of,  253, 

254 
operation  of  "Weber  for  excision  of,  252 
253 


Jones,  method  of  arthrodesis  of  elbow,  355, 
356 

method  of  transplantation  of  tendons,  392-401 

Jonnesco,  o])eration  for  cancer  of  mammary 
glands,  469 

,ludd,  incision  for  operation  on  double  ingui- 
nal hernia,  513.  514 

Judd,  operation  on  diverticulum  of  esoph- 
agus, 322,  323 

K 

Keen,   operation   for   puncture   of  ventricle, 

275 
Kidney,  operations  on,  663-674 

congenital  cystic,  method  of  Lund,  669,  670 
fixation,   664-666 
incisions  for,   510-512 
Kimpton  and  Brown,   method   of   transfusion 

of  blood,  65 
Kirk  and  Lewis,  regeneration  of  nerves,  141 
Knee  joint,  amputation  at,  379,  380 

method  of  Gritti-Stokes,  380,  381 
method   of   Stephen   Smith,   379,   380 
arthroplasty  of,  420 
excision   of,   415 
excision  of  semilunar  cartilage  from,  413, 

414 
operation  for  foreign  bodies  in,  414 
Knots,  tying  of,  47-50 

:nethod  of  Grant,  48-50 
Kondoleon  operation  for  elephantiasis,  427, 
428 
for  lymph  edema  of  arm,  368 
for  local  edema,  38 


Laminectomy,  290-296 

LaEoque,  operation  for  inguinal  hernia,  490- 

493 
Larynx,  operations  on,  316-321 
Laryngectomy,  318-321 

method   of   Bevau,    318-321 
Laryugotomy,  316 
LeCoute,   operation  for   amputation  of  upper 

extremity,    349,    350 
Leg,  amputation  of,  376-379 

method  of  Hey,  376,   377 
Lespinasse,  operation  on  vas  deferaus,  701-703 
Lewis,   Dean,    operation   on   mammary   gland, 
464,  465 
reconstruction  of  tendons  and  fingers,  361- 

363 
regeneration  of  nerves,  141 
regeneration  of  tendons,  362 
use   of   fascial   tube   in   suturing   nerves, 
145,    146 
Lewis   and   Huber,   method   of   prevention   of 

neuromas,  334 
LeT\-isohns,   citrate   method   of   transfusion   of 

blood,  66-68 
Lexer,  excision  of  aneurism,   75 
Ligation  of  blood  vessels,  97-117 
method  of  Binnie,  98,  99 
abdominal   aorta,   110 
anterior  tibial  artery,   116 


718 


INDEX 


Ligation  of  blood  vessels — Cont'd 
axillaiy  artery,   108 
brachial  artery,  109 
common  carotid  artery,   101,   102 
common  iliac  artery,  110,  111 
dorsalis  pedis  artery,  116 
external  carotid  artery,  102,  103 
external  iliac  artery,  112,  113 
femoral  artery,  113-115 
innominate  artery,  100,   101 
internal  carotid  artery,  105 
internal  iliac  artery,  111,  112 
inferior  thyroid  artery,   107 
popliteal  artery,  115,  116 
posterior  tibial  artery,  117 
radial  and  ulnar  artery,  109,  110 
subclavian  artery,  105-107 
superior  thyroid  arteries,   104 
vertebral   artery,    107 
Ligation  of  femoral  vein  for  threatened  gan- 
grene, 95,  96 
Ligature  material,  45-47 
Lindemann,  method   of  transfusion   of  blood, 

65,   66 
Lips,  operations  on,   198-210 
lower,  200-205 
mucosa  of,  206-208 
upper,  198-200 
Liver  and  bile  tracts,  operations  on,  520-535 
operation  on  abscess  of,  520,  521 
on  cirrhosis  of,  534,  535 
on  tumors  of,  521,  522 
Long,  J.  W.,  method  of  enterostomy,  589-592 

operation  for  pericolonic  bands,  638 
Lower  extremity,  amputation  of,  370-385 
neuromas  in  amputation  of,  370 
general  principles  in  amputation  of,  370, 

371 
operation  on  tendons  of,  385-401 
transplantation  of,  387,  388 
Lumbar  puncture,  288-290 
Lund,  operation  for  congenital  cystic  kidney, 

669,  670 
Lungs,  operations  on,  443-458 

abscess  of,  method  of  Bevan,  444-458 
resection  of,  447-451 

method  of  Robinson,  447-451 
Lymph  circulation,  reversal  of,   35-43 
Lymph  edema  of  arm,  operation  for,  366-368 

methods  of  Kondoleon,  368 
Lymphatic  glands  of  neck,  310-312 


M 


Mammary  gland,   operations   on,  462-476 

for  cancer  of,  method  of  Halsted,  467- 
469 
method  of  Jackson,  469 
method   of   Rodman,   470-476 
for  hernia  of,  method  of  Harris,  465- 

467 
general  princij)les  of,  462,  463 
method  of  Dean  Lewis,  464 
method  of  Warren,  463 
Mann,  Frank,  on  sequestration  anemia,   58 


Matas,  treatment  of  aneurism,  122-125 

treatment  of  aneurism  by  gradual  oblitera- 
tion, 119,  120 
treatment    of   arteriovenous   aneurisms,    135 
metliod  of  endo-aneurismorrhaphy,  123-125 
Mayo,  C.  H.,  operation  for  cancer  of  rectosig- 
moid, 640-646 
operation  on  cervical  sympathetic,  325,  326 
operation  on  harelip,  188 
operation  for  hallux  valgus,  405 
operation  for  hypospadias,  709,  710 
operation  on  thyroid  gland,  327-329 
operation  on  varicose  veins,  429,  430 
Mavo,  W.  J.,  incision  for  nephrectomy,   663, 
664 
method  of  Kraske  's  excision  of  rectum,  641- 

644 
operation    for   incisional    or   ventral  hernia, 

503 
operation   for   reconstruction   of   bile    duct, 

533,  534 
operation  for  umbilical  hernia,  499-502 
Meckel,  diverticulum  of  intestine,  618,  619 
Mediastinum,    oi^eration    for   tumors   in,   451, 

452 
Meningocele  of  brain,  277-279 
Metal  in  bone  plating,  160,  161 
Metatarsal  bones,  excision  of,  573,  574 
Mischowitz,  operation  for  prolapse  of  rectum, 

649,  650 
Mixter,  method  of  sigmoidostomy,  602 

operation  on  stricture  of  esophagus,  323 
Mosetig-Moorhof,  filling,  423 
Mouth,  operation  on  angle  of,  205,  206 
Murphy,  John  B.,  transplantation  of  tendons 
in  finger,  364-366 
transplantation  of  tendons  in  forearm,  364- 

366 
transplantation  of  tendons  in  wrist,  364-366 

MC 

McArthur,  operation  on  hypophysis,  275,  276 
Macewen,  needling  of  aneurisms,  118 

N 

Nail,  ingrowing,  oj^erations  for,  406,  407 
Neck,  operations  on,  303-330 

arrangement  of  lymphatic  glands  in,  310- 

312 
block  dissection  of,  312-316 
block  operation  on,  method  of  Crile,  312- 

316 
branchial  cysts  of,  305 
branchial  fistula  of,  305 
cancer  of,  310-316 
cysts  of,  304-308 
diffuse  lipoma,  324,  325 
general  principles  of,  303,  304 
malignant  gro^rths  of,  310-316 
metastatic  cancer  of,  312-316 
tuberculous  glands  of,  309,  310 
method  of  Dowd,  309  to  310 
Nephrectomy,  666-670 

incision  of  W.  J.  Mayo  for,  663,  664 
subscapular,   668 


INDEX 


719 


Ncpliropi'xy,   (i(i4-G60 
Nophrotoiny,  ()70,  (i7l 
Norvos,  operations  on,  141-1;")G 
bridoini^-  defects,  146-150 
facial,  repair  of,  150-153 
facial,  operations  on,  153 
reoeneration    of,    method    of    Kirk    and 

Lewis,  141 
repair   of  defect   of,  method  of  Elsberg, 

146-148 
treatment  of  amputation,  334 
use  of  fascial  tube  in  suturing,  method  of 

Dean  Lewis,   145,   146 
bi'achial  plexus,  153-155 

method  of  Sharpe,  154,  155 
brachial  plexus  paralysis,  transplantation 
of  muscles  for,  155  to  156 
Neuralgia  of  5tli  nerve,  peripheral  operations 

for,   258-260 
Neuroma   in   amputation   of   lower   extremity, 
370 
in    amputation    of    stumps,    prevention    of, 
method  of  Huber  and  Lewis,  334, 
370 
Nose,  operations  on,  224-235 
operation  on  columna  of,  228 
reconstruction  of  ala,  225-228 

method  of  Baldwin,  232,  233 
bv   Indian   method,    229-231 
by  Italian  method,  231,  232 
' '  saddle  ' ',   operations  for,    234-236 

O 

Ochsner,  operation  on  stricture  of  esophagus, 

323 
Orbital   socket,   operation  of   J.   S.   Davis  on, 

220-222 
Osteotomy,  417-420 
cuneiform,   418 

method  of  Macewen,  417,  418 
method  of  Ogston,  419,  420 
method  of  Reeves,  419,  420 
Osteomyelitis,  operations  for,  421-426 

method  of  Mosetig-Moorhof,  plug  in,  423 
Owen,  operation  on  harelip,  190,  191 


Pancreas,  operation  for  cancer  of,  method  of 
Coffey,   535-538 

operation   for   cyst   of,   539 
Pancreatitis,  operation  for,  38,  539 
Parotid  gland,  operations  on,  240-245 
Patella,  operation  for  chronic  dislocation  of, 

method  of  Goldthwait,  413 
Penis,  operations  on,  707-712 

amputation  of,   711,  712 

excision  of,  711,   712 
Percy,  method  of  transfusion  of  blood,  65,  66 
Pericardium,  operations  on,  452,  453 
Pericolonic  bands,  637-639 
Peritoneum,  drainage   of,  36,  37 

foreign  bodies  in,  42 

irritating  lubricants   in,   Cubbins   and   Abt, 
74 


Peroneus,  traiisi)hintatiou  of  tendons  of,  389- 

394 
Pfannenstiel,   incision  of,  509,   513,   514 
Pharynx,  operations  on,   321,  322 
Pharyngotomy,   321,   322 
Physiologic  principles  in   surgical  operations, 

29-34 
Plastic  surgery,  principles  of,  172-186 
defects  in,  175-178 
development  of  blood  supplv  of  pedicle  in, 

175,   178-181 
"jumping"  and  "waltzing"  flaps  in,  180 
suture  in,  45-47 
treatment  of  depressed  scars,  method  of  Es- 

ser,  186 
treatment  of  pedicles  of  flaps  in,  175,  178- 

181 
tubing  pedicle  in,  178-180 
types   of   operations   in   closing   defects   in, 
175-178 
Plating  of  bone,  160,  161 
Pneumothorax,  artificial,  449-451 
Polya-Balfour  excision  of  stomach,  574-578 
Prostate  gland,  operations  on,  690-700 
Prostatectomy,  690-700 

operation  for  cancer  of,  method  of  Young, 

697-700 
perineal,   method  of  Young,   695-697 
suprapubic,  691-694 
Pruritis  ani,  operations  for,  659  to  661 

method   of  Terrell,   659-661 
Pulmonary  embolism,  operation  for,  454-458 

method  of  Trendelenburg,  454-458 
Pyelotomy,  671  to  674 

Pylorus,    congenital    stenosis,    operation    for, 
581-584 
method  of  Rammstedt,  582 
method  of  Strauss,  582  to  584 
Pyloroplasty,  according  to  Finney,  549-551 
according  to  Heiueke-Mikulicz,  551 
according  to  Horsley,  552-564 

E 

Eammstedt,  operation  for  congenital  stenosis 

of  pylorus,  582 
Reconstruction  of  the  bile  duct,  34 
Seid,  treatment  of  aneurism,  120 

method  of  locating  centers  in  the   brain, 
265 
Rectum,   operation   for   abscess   of,   650 
for  cancer  of,  639-648 
for   eaz-ly   cancer    of,    method    of    Bevan, 

645-648 
for  fistula  of,  650-652 

Kraske's    excision,    method    of    W.    J. 
Mayo,  641-644 
for  prolapse  of,  646-650 

method  of  Moschcowitz,  649,  650 
for  stricture  of,  652,  653 
for  ulceration  of,  652,  653 
Rectosigmoid,   operation   for   cancer   of,    639- 
643 
method  of  C.  H.  Mayo,  640-646 
Reverdin,  method  of  skin  grafting,  182 
Reversal  of  circulation  of  blood,  30,  31,  92-90 
method  of  Horsley,  92-95 


720 


INDEX 


Reversal  of  circulation  of  blood — ('out  "d 
method  of  DeWitt  Stetton,  93,  94 
method  of  Wliitehead,  92-94 
Reversal  of  lymph  circulation,  35-43 
Resection    of    abdominal    aorta,    experimental 

specimen,   89 
Ribs,    operations   on,    432-443 
cervical,  308 

typhoid,  operation  for,  43(i,  437 
Rinkenberger,   F.   W.,   method   of   location   of 

centers  of  brain,  265,  266 
Robinson,    operation    for    chronic    empyema, 
443 
operation  for  resection  of  lung,  447-451 
Rodman,    operation    for    cancer    of    mammary 

gland,  470-476 
Rose,  operation  on  harelij?,  188-190 
Roiix,   operation  of   gastroenterostomy,   569 
Russell,  oi^eration  on  hypospadias,  709-711 

S 

Sacral  dermoid,  operation  for,  661,  662 

Salivary  fistula,  operations  for,  240-242 

Scalp,  operations  on,  261-264 

Scapula,  excision  of,  560,  561 

Sears,  depressed,  method  of  treatment,  186 

gradual  excision  of,   172,  173 
Sciatic  nerve,  operation  for  neuralgia  of,  430, 

431 
Sciatica,  operation  for,  430,  431 
Scrotum,  redundant,  resection  of,  706 
Seelig,  operation  for  femoral  hernia,  495-497 
Semilunar  cartilage,  excision  of,  413,  414 
Seminal  vesicles,  operations  on,  700 
method  of  Cunningham,  700 
method  of  Fuller,  700 
Sequestration   anemia   in   surgical   operations, 

57,  58 
Sharpe,     method     of    operation    on     brachial 

plexus,  154,  155 
Shock  in  sui'gical  operations,  54-56 
Shoulder  joint,  amputation  at,  347-349 

excision  of,  353-355 
Sigmoid,  operation  for  cancer  of,  639-643 
Sigmoidostomy,  602 

method  of  Mixter,  602 
Sistrunk,    operation    on    thvroglossal    cvsts, 
305-308 
operation  on  thyroglossal  fistula,  305-308 
Skin  grafting,  34,  173,  174,  180-186 
contractions  after,  173,  174 
method  of  J.  S.  Davis,  182 
method   of  Reverdin,   182 
method  of  Thiersch,  180-184 
method  of  Wolfe-Krause,  184-186 
transplantation  of  whole,  180,  184-186 
Skull,   operations   on,   261-287 

control  of  hemorrhage  from,  264 
old  depressed  fractures  of,  269-272 
osteoi)lastic  flap  of,  263-265 
Spine,   operations   on,   288-302 
lumbar  puncture  of,  288-290 
Spina  bifida,  296-302 

classifications  of,  296-298 
operations  on,  method  of  Albee,   301-302 
method  of  Babcock,  300-302 


Spina  bifida,  <i[)cratioiis — Cont'd 
method  of  Frazicr,   298-300 
with  hydrocephalus,  297,  298 
Spinal  anesthesia,  289,  290 
Spleen,  operations  on,  539-542 

removal  of,  method  of  Balfour,  539-542 
Starr,  method  of  amputation  of  lower  extrem- 
ity, 370-372 
Stetten,   DcWitt,   reversal   of   circulation,   93, 

94 
Stomach,  operations  on,  543-584 
excision  of,  574-578 

method  of  Polya-Balfour,  574-578 
operation  for  fjtosis  of,  method   of  Beyea, 
modified  by   Horslev,   544-546 
method  of  Coffey,  543 
general   principles   for    operation    for    ulcer 

of,  547-552 
excision   of   ulcer  of,   570-573 
operation  for  ulcer  of,  547-574 
technie   in   suturing  wounds  in,   585,   586 
Strauss,   operation  for   congenital  stenosis   of 

pylorus,  582-584 
Subacromial  bursitis,  operation  for,  method  of 
Codman,  369 
method   of  Brickner,   369 
Sullivan,  operation  for  reconstruction  of  bile 

duct,  533 
Surgical  drainage,  35-43 

classification  of,  36 
Suturing  blood  vessels,   69-91 
indications  for,  69,  70 
method  of  Carrel,   71-73 
method  of  Horsley,  77-86 
lateral  wounds,  90,  91 
Suture  material,  45-47 
Szvmonowski,    operation    for    reconstruction 

of  ear,   223-224 
Sympathetic,  cervical,  operations  on,  325,  326 


Tarsometatarsal   joint,    amputation   at,    374, 

375 
Technie  in  surgery,  44-50 
Teeth,  abscesses  of,  39 

Tendons    of   lower    extremitv,    operations    on, 
385-401 
transplantation  of  in  lower  extremity,  387, 
388 
Tendons,  regeneration  of,  362 
suture  of,  method  of  Frisch,  362 
transplantation   of   peroneus,   387,    388 
method  of  Jones,  392-401 
Tenotomy,   385-387 

Terrell,  E.  H.,  operation  for  hemorrhoids,  654, 
655 
operation  for  pruritis   ani,   659-661 
Testicle,    operations    on,    703-707 
excision  of,   703-707 

operation  for  undescended,  method   of  Be- 
van,  705,  706 
Thiersch,  method  of  skin  grafting,  180-184 
Thigh,  amputation  of,  380-383 
Thompson,  operation  on  hypospadias,  709-711 
Thorax,  operations  on,  432-461 

general  principles  of  operations  on,  432-435 


INDEX 


721 


Tlidrax — Cont  M 

openitiou  for  })ar;ilysis  of  nmsi-les  of,  548- 
r>(l() 
Tlii-onil)iis  foniiatiou   in   sulurins'  blood  ves- 
sels, 70,  7-1 
Thyroid  gland,  operations  on,  32l)-3o0 
method  of  Balfour,  330 
method  of  Bartlett,  330 
method  of  C.  H.  Mayo,  327-329 
Thyroglossal  cysts,  operations  on,  305-308 
method  of  Sistrunk,   305-308 
fistula,  operations  on,  305-308 
method  of  Sistrunk,  305-308 
Toes,  amputation  of,  371-373 

operation  for   ingrowing  nail  of,   406,   407 
Tongue,   oj)erations   on,   245-251 

excision  of,  method  of  Ashhurst,  246,  249 
method  of  Blair,  249-251 
Torticollis,  308,  309 
Trachea,  operations  on,   316-318 
Tracheotomy,   316-317 
Transfusion  of  blood,  59-68 

citrate  method  of  Lewisohn,  66-68 
method  of  Bernheim,  64,  65 
method  of  Crile,  62 
method  of  Horsley,  60,  77-86 
method  of  Kimpton  and  Brown,  65 
method   of   Lindemaun,   65,   66 
method  of  Percy,  65,  66 
Transplantation  of  organs,  34 
Trendelenburg,   operation  for  pulmonary   em- 
bolism, 454-458 
Trifacial  nerve,  jDeripheral  operations  on,  258- 

260 
Tuberculous  glands  of  neck,  309,  310 
Tuberculous   peritonitis,   treatment   of,   30 
Tubing  pedicle  in  plastic  surgery,  method  of 

Gillie,  178,   180 
Tying  knots,  47-50 
Typhoid  rib,  operation  for,  436,  437 


U 

Umbilical  hernia,  operations  for,  499-502 
Ununited  fractures  of  bones,   166-168 
Upper  extremity,   ox^erations  on,   331-369 
Ureter,    operations   on,   331-369 

transplantation   of,   678-683 
Urethrotomy,  external,  688,   689 

V 

Varicose  veins,  operations  for,  428-430 

method  of  C.  H.  Mayo,  429,  430 
Varicocele,   operations   for,   701-707 
method  of  Lespinasse,   701-703 
Vas  deferens,  operations  on,  701-703 
Vein,  varicose,  operations  for,  428-430 
Ventricle,  brain,  puncture  of,  275 
Ventral  hernia  operations  for,  502-504 

W 

Warren,  operation  on  mammary  gland,  463 
Web  fingers,  operations  for,  360,  361 
Weber,  operation  for  excision  of  upper  jaw, 

252,  253 
Weir,  operation  for  ' '  trigger '  'finger,  359 
Whitehead,  E.  H.,  on  reversal  of  circulation, 

92-94 
Willis,    operation   for   cholecystectomy,    527 
Wolff's  laAv  in  bone  grafting,  158 
Wolfe-Krause,  method  of  skin  grafting    173, 

184-186 
Wrist  joint,  excision  of,  350,  351 
Wrist,  transplantation  of  tendons  of,  method 

of  Murphy,  364-366 
Wry  neck,  308,  309 
Wyeth,  amputation  at  hip  joint,  383,  384 

Y 

Young,  H.   H.,  operation  for  cancer  of  pros- 
tate, 697-700 
method   of  perineal  prostatectomy,   695-697 


COLUMBIA   UNIVERSITY 

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DATE  BORROWED 


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Operativii  ■iiniii 


2002105675 


*»'«  i  7  1922 


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